BURNS

OVERVIEW
• A burn is a type of injury to skin or other tissues
by heat, cold, electricity, chemicals, friction, or
radiation. Most burns are due to heat from hot
liquids, solids, or fire. While rates are similar for
males and females the underlying causes often
differ.
• Burns are a global public health problem,
accounting for an estimated 180 000 deaths
annually. The majority of these occur in low- and
middle-income countries and almost two thirds
occur in the WHO African and South-East Asia
regions.

ANATOMY AND PHYSIOLOGY

• Main components:
− Skin
− Hair
− Oil and sweat gland
− Sensory receptors

• Skin Functions
− Regulated blood temperature (dilating capillaries
and sweating)
− Stores blood
− Protects from external environment
− Detects cutaneous sensations (pressure, hear,
texture, etc.)
− Excretes and absorbs substances
− Synthesizes vitamin D
EXTENT OF BODY SURFACE AREA
CHARACTERISTICS ACCORDING TO INJURED
DEPTH Rule of nines
− 9% for whole head
− 9% for left arm
− 9% for right arm
− 18% for anterior torso
− (chest/stomach)
− 18% for posterior torso
(back)
− 18% for left leg
− 18% for right leg

− (If you are observant enough to notice this only

adds up to 99%, you are smart enough to figure out
where the other 1% is located!)
Palmer method General Management
− In patient with scattered burns, a method to • Remove Burning Agent
estimate the percentage of burn is the palm • Remove clothing's and jewelry
method. The size of the patient’s palm is
approximately 1% of total body surface area and
the palm of the hand excluding the fingers, is
approximately 0.5% of TBSA.Clean piece of paper
is cut to the size of hand and through that the
percentage of burns is assessed.

MEDICAL MANAGEMENT
4 major goals relating to burns:
1. Prevention
Management of 1st degree
2. Institution of lifesaving measures
• Cool the burns
3. Prevention of disability and disfigurement
• Protect the burns
4. Rehabilitation
• Pain management
Emergency Medical Care

• Definitive burn care can be divided into four

phases.

Management of 2nd degree

• Cool the burns
• Protect the burns
• Shock prevention

Management of 3rd degree

• Call 117
• DO NOT remove burned clothes
• DO NOT put extensive/ severe burns in cold water
• Check for circulation
• Protect the burns
• Shock prevention
Management of 3rd degree
• FOR AIRWAY BURNS
− DO NOT put pillow underneath victims head
− Encourage person with facial burn to sit up
− Continue monitoring circulation
Burn Shock
• Sets in during a 6- to 8-hour period
• Mortality increases if fluid resuscitation is delayed
longer than 2 hours.
• Obtain vascular access and begin fluid
resuscitation in the field.
Fluid Resuscitation
• Needed for patients with burns covering more
than 20% of the body’s surface
− If delayed more than 2 hours, mortality increases.
− Begin to deliver as soon as is reasonable.
Pain Management
• Assess pain before administering analgesia.
− Burn patients may require higher doses.
• Pain medication is best given via IV route.
• Narcotics remain the drugs of choice.
PHARMACOLOGIC
• Morphine sulfate
• Fentanyl
• Patient-controlled analgesia (PCA)
• MS Contin or oxycodone (OxyContin)
• lorazepam (Ativan) and midazolam (Versed)
Pain Management
NON-PHARMACOLOGIC
• relaxation techniques,
• deep breathing exercises,
• distraction,
•guided imagery,
• hypnosis,
• therapeutic touch,
• humor,
• information giving, and
• music therapy
Thermal Burns
• Superficial burns − If patient is reached within the
Nutrition Management first hour, immerse the burn in cool water or apply
• Hyper metabolism develops as a response to cold compresses.
injury − Transport the patient in a comfortable position.
• If TBSA >40%, lean body weight ↓ by 25% over
the first 3 weeks
• Patient with major burn needs high calorie in the
form of:
− CHO (50%),
− protein (20%)
− fat (30%) and
− Some vitamins & minerals

Curreri formula
• Age 16–59 years: (25)W + (40)TBSA
• Age 60+ years: (20)W + (65)TBSA

Sutherland formula
•Children: 60 kcal /kg + 35 kcal%TBSA
•Adults: 20 kcal /kg + 70 kcal%TBSA Thermal Burns
• Partial-thickness
Protein needs − Cool burn with water or apply wet dressings.
• Greatest nitrogen losses between days 5 and 10 − Elevate extremities.
•20% of kilocalories should be provided by proteins − Establish IV fluids.
•ranging from 1.5 to 4.0 g of protein per kilogram of − Administer pain medication.
body weight every 24 hours
• Full-thickness
Nutrition Management − Assess pain and administer pain medication.
− Dry dressings are often used.
− Begin fluid resuscitation.

Thermal Inhalation Burns

• Apply cool mist or aerosol therapy.
− Apply ice pack to the throat if mister is not
available.
• Aggressive airway management may be
necessary.
Chemical Burns of the Skin
• Burn progresses as long as the substance
remains in contact with the skin.
• Typical management: removal of chemical
− Solutions require flushing with water.
− Powders require brushing off before washing.

Chemical Burns of the Skin

• Acid burns
− Easy to neutralize
− Cause destruction and coagulation of tissues

• Alkali burns
− More difficult to neutralize
− Effects are pronounced in burns of the eye.

Chemical Burns of the Skin Inhalation Burns from Other Toxic

• Management Chemicals
− Flush with copious • HF acid is a special case.
amounts of water. − Aggressively binds with calcium ions
− Rapidly remove the − May require the administration of IV
patient’s clothing. calcium
− Wash skin folds.
− Once washing is • Management
complete, wash again. − Maintain an acceptable O2 saturation
level.
− Dry lime − Monitor for signs of airway compromise.
• Remove clothing and brush as much as − Aerosolized beta-agonists are usually
you can from the skin. helpful.
• Flush copiously with a garden hose or
shower. Chemical Burns of the Eye
− Sodium metals • Chemicals known to cause burns to the eyes
• Cover burn with oil. include:
− Acids
− Hydrofluoric (HF) acid − Alkalis
• Calcium chloride (CaCl) jelly may reduce − Dry chemicals
injury. − Phenols
− Gasoline or diesel fuel
• Remove with soap solution.
− Hot tar Chemical Burns of the Eye
• Immerse in cold water. • Assessment and management
− Flush with copious amounts of water.
Inhalation Burns from Other Toxic − If the patient wears contact lenses, pause for
Chemicals removal.
• The solubility properties of the gas will often − Patch the eyes with lightly applied dressings.
determine where it affects the airway.
Chemical Burns of the Eye
• Assessment and management
− The Morgan lens may make eye irrigation more
comfortable and effective.
Electrical Burns and Associated Injuries
• Electrical burns have a strong possibility of severe
internal injury.
− Two common causes of death from
electrical injury are asphyxia and cardiac
arrest.
− Electricity can disrupt the nervous system.
• Management
− Prioritize patient care.
− Administer early O2 therapy.
− Manage for impending shock.
− Make transport decisions early.
Lightning-Related Injuries
• A direct hit is not needed to be injured.
• If an object is a better conductor of
electricity than the air, it will “attract”
lightning.
• The best treatment is prevention.
− Don’t be the tallest conductor.
− Don’t stand under or near the
tallest conductor.
− Take shelter in a substantial
structure.
− Avoid touching good conductors.
• Management
− Perform CPR as needed.
− Administer supplemental oxygen.
− Monitor cardiac rhythm.
− Insert a large-bore IV catheter.
− Cover burns with dry, sterile dressings.
− Splint fractures.
Radiation Burns
• Acute radiation syndrome
− Causes hematologic, central nervous
system, and gastrointestinal changes
− Unresponsive patients who vomit within
10 minutes of exposure will not survive
• Radiation contact burns
− Injury could resemble anything from
superficial sunburn to a chemical burn.
− Burns could appear within hours or days.
• Assessment
− Determine if the scene is safe.
− Determine what protective gear is needed.
− Assess mental status and ABCs.
− Prioritize the patient’s care.
• Management
− Decontaminate patients before transport.
− Gently irrigate open wounds.
− Notify the ED as soon as possible.
− Limit your duration of exposure.
− Increase your distance from the source.
NURSING MANAGEMENT
1. ASSESSMENT
2. NURSING DIAGNOSIS
− Impaired gas exchange
− Ineffective airway clearance
− Fluid volume deficit
− Hypothermia
− Pain
− Anxiety
3. PLANNING & GOALS
− Maintenance of adequate tissue
oxygenation.
− Maintenance of patent airway and
adequate airway clearance.
− Restoration of optimal fluid and electrolyte
balance and perfusion of vital organs.
− Maintenance of adequate body
temperature.
− Control of pain.
 − Minimization of patient’s and family’s
anxiety.
-Nursing Priorities
-Maintain patent airway/respiratory function.
-Restore hemodynamic stability/circulating
volume.
-Alleviate pain.
-Prevent complications.
-Provide emotional support for
patient/significant other (SO).
-Provide information about condition,
prognosis, and treatment.
4. NURSING INTERVENTIONS:
− Promoting Gas Exchange and Airway
Clearance
− Restoring fluid and Electrolyte Balance
− Maintaining Normal Body Temperature
− Minimizing Pain and Anxiety
− Monitoring and Managing Potential
Complications
− Restoring Normal fluid Balance
− Provide a clean and safe environment;
protect patient from sources of cross
contamination (e.g., visitors, other patients,
staff, equipment).
−Maintaining Adequate Nutrition
−Promoting Skin Integrity
−Relieving Pain and Discomfort
−Promoting Physical Mobility
−Strengthening Coping Strategies
−Supporting Patient and Family Processes
−Monitoring and Managing Potential
Complications
−Promoting Activity Tolerance
−Improving Body Image and Self-Concept
−Teaching Self-care
5. EVALUATION:
− Absence of dyspnea.
− Respiratory rate between 12 and 20
breaths/min.
− Lungs clear on auscultation,
− Arterial oxygen saturation greater than
96% by pulse oximetry.
− ABG levels within normal limits.
− Patent airway
− Respiratory secretions are minimal,
colorless, and thin.
−Urine output between 0.5 and 1.0 mL/kg/h.
−Blood pressure higher than 90/60 mmHg.
−Heart rate less than 120 bpm.
−Body temperature remains between
36.1ºC and 38.3ºC
TOXICOLOGY:
Poisoning and Substance abuse
Toxicology
− Recognition and management of
• Carbon monoxide poisoning
• Nerve agent poisoning
− How and when to contact a poison control center
Anatomy, physiology, pathophysiology,
assessment, and management of
− Inhaled poisons
− Ingested poisons
− Injected poisons
− Absorbed poisons
− Alcohol intoxication and withdrawal
− Opiate toxidrome
Anatomy, physiology epidemiology,
pathophysiology, psychosocial impact,
presentations, prognosis, and management of the
following toxidromes and poisonings (cont’d)
− Alcohol intoxication and withdrawal
− Over-the-counter and prescription
medications
− Carbon monoxide
− Illegal drugs
− Herbal preparations
Introduction
• EMRs are often called to treat patients who are
abusing licit or illicit drugs.
Introduction
• A poison is a substance that causes illness or
death when eaten, drunk, inhaled, injected, or
absorbed in relatively small quantities.
• EMRs can save patients’ lives by quickly
recognizing and promptly treating serious
poisonings.
Patient Assessment for Poisoning (1 of 5) • Dose
• Poisoning can be classified according to the way
the poison enters the body. Types of Toxicologic Emergencies
− Ingestion: Poison enters through the • Unintentional
mouth and is absorbed by the digestive − Can occur in many ways, including:
system. • Children who mistakenly put poison in their
− Inhalation: Poison enters through the mouths
mouth or nose and is absorbed by the
mucous membranes lining the respiratory • Intentional
system. − “Overdose” or “intimate crime”
− Injection: Poison enters through a small
opening in the skin and spreads through the
circulatory system.
− Absorption: Poison enters through intact
skin and spreads through the circulatory
system.

• General assessment and treatment

− Follow the patient assessment sequence.
− Obtain a thorough history from the patient
or from bystanders.
− Be alert for visual clues that may indicate
poisoning.
− Much of the emergency care depends on
the patient’s signs and symptoms.

• Poison
− Substance that is toxic by nature, no
matter how it gets into the body or how
much is taken
• Drug
− Substance that has a therapeutic effect
when given in the appropriate:
• Circumstances
 − Possibilities vary by geographic location.
− Some poisons are neurotoxic; others
produce localized or systemic reactions.
− Physical findings will provide clues.
− The patient may be able to identify the
culprit.

• Poisoning by absorption
− Poisonings by pesticides are often the
most serious.

Understanding and Using Toxidromes

Poison Centers
• Toxidrome: the syndrome-like symptoms of a
• Poison Centers can provide a rundown on a
class or group of similar poisonous agents
poison’s:
− Ingestion
− Toxic potential
− Steps to negate effects

• Never hesitate to call!

• +63.2.5241078 UP NPMCC

Routes of Absorption
• Poisoning by ingestion
− Immediate damage or delayed effects

• What is ingested?
Ingested Poisons
• Why was it ingested?
• More than 80% of all cases of poisonings are
− Generally provides time for
caused by ingestion.
identification/treatment
• Chemical burns, odors, or stains may be found
− Management: remove or neutralize the
around the patient’s mouth.
poison
• Signs and symptoms
− Nausea
• Poisoning by inhalation
− Vomiting
− Toxic agent may be present in the
− Abdominal pain
environment.
• Signs and symptoms (cont’d)
− Diarrhea
• Patient will inhale the toxin as long as he/she
− Abnormal or decreased respirations
remains in the environment.
− Loss of consciousness
• Likely to find more than one patient
− Seizures
− May be accidental or intentional
− Window for identification/treatment is
Treatment for Ingested Poisons
limited.
• Identify the poison.
− Consider scene safety.
• Call the National Poison Center for
− Look for information to help identify toxin.
instructions, and follow these instructions.
− Utilize the Poison Center and medical
• If you are unable to contact the poison
control.
center, dilute the poison by giving water.
− Correct hypoxia.
• Arrange for prompt transport to a hospital.
• Poisoning by injection
− Usually gain access as the result of:
• Stings or bites from insects and animals
• Abuse of intravenously administered drugs
• Dilution
− Most poisons can be diluted by giving the
patient large quantities of water.
− The patient must be conscious and able to
swallow
• Activated charcoal
− Finely ground powder mixed with water
− Works by binding to the poison, thereby
preventing the poison from being absorbed
in the patient’s digestive tract
− Do not give if the patient:
• Has ingested an acid or an alkali
• Has ingested a base
• Is unconscious
− Usual dose:
• 25 to 50 grams for an adult patient
• 12.5 to 25 grams for a pediatric
patient
− Serve it in a covered cup and give the
patient a straw.
• Vomiting
− In the past, syrup of ipecac was used to
induce vomiting.
− Today, it is recommended in only a few
situations.
− Inducing vomiting may cause the patient
to inhale the vomit into the lungs.
− Activated charcoal is considered more
effective and safer than syrup of ipecac.
• Occurs if a toxic substance is breathed in and
absorbed through the lungs
− Some toxic substances (carbon
monoxide) are very poisonous but not
irritating.
− Other toxic gases (chlorine gas and
ammonia) are very irritating to the
respiratory tract.
• Signs and symptoms
− Respiratory distress
− Dizziness
− Cough
− Headache
− Hoarseness
− Confusion
− Chest pain
Carbon Monoxide
• Common causes of carbon monoxide poisoning
include:
− Improperly vented heating appliances
− Smoke (burning buildings)
• Signs and symptoms
− Headache
− Nausea
− Disorientation
− Unconsciousness
− Flulike symptoms
• If you find several patients together who all report
these symptoms, remove everyone from the
structure or vehicle.
Irritants (1 of 4)
• Ammonia
− Often found in agricultural settings
− Has a strong, irritating odor
− Is highly toxic
− Causes violent coughing and skin burns
− Anyone who enters an environment
containing ammonia must wear a proper
encapsulating suit with a SCBA.
• Chlorine
− Found around swimming pools and water
treatment plants
− Is severely irritating to the lungs and
upper respiratory tract
− Causes violent coughing and skin burns
− Anyone who enters an environment
containing chlorine must wear a proper
encapsulating suit with a SCBA.
• The presence of hazardous materials that are
toxic and those in which there is a danger of fire or
explosion should be indicated by the appropriate
placards.
Treatment for Inhaled Poisons
• Remove the patient from the source of the gas.
− If the patient is not breathing, begin
mouth-to-mask breathing.
− If the patient is breathing, administer large
quantities of oxygen.
• Arrange for prompt transport.
• You may have to evacuate people first.
Injected Poisons
• The two major causes of poisoning by injection
are:
− Animal bites and stings
− Toxic injection
• Signs and symptoms
− Obvious injury site (bite or sting marks)
− Tenderness
 − Swelling 7 Most Dangerous Snakes in The
− Red streaks radiating from the injection Philippines to Avoid (2022)
site
− Weakness Wagler’s Pit Viper
− Dizziness • This snake is commonly identified by its
− Localized pain triangularshaped head.
− Itching

Treatment for Insect Stings and Bites

• Keep the patient quiet and still.
• A light constricting band may be used if
there is severe swelling.
• Apply ice packs to reduce swelling and
pain.
• Some people may experience an extreme
allergic reaction and go into anaphylactic
shock.
• Signs and symptoms of anaphylactic
shock
− Itching
− Hives King Cobra
− Swelling • This is amongst the most venomous snakes in the
− Wheezing and severe respiratory world and when ‘standing’ in a striking pose it can
distress face a human eye-to-eye. King Cobras can lift a
− Generalized weakness third of their body off the floor and still maintain
− Loss of consciousness momentum for an attack, making them one of the
− Rapid, weak pulse most notorious snakes in the region.
− Rapid, shallow breathing

• Treatment for anaphylactic shock

− Maintain the patient’s ABCs.
− Administer oxygen if available.
− Elevating the patient’s legs may
help.
− Remove the allergen if possible.
− Monitor the patient’s vital signs.
− If the patient’s condition
progresses to the point of respiratory
or cardiac arrest, begin mouth-to-
mask breathing or CPR.
− Immediately arrange for rapid
transport. Yellow-Lipped Sea Krait
− If the patient has a prescribed • This highly venomous sea snake is easy to
autoinjector, help the patient use it. identify with its black head, with a yellow upper lip,
• Place the tip of the auto-injector against snout and cheeks. The Yellow-Lipped Sea Krait’s
the outer thigh. body is a light grey colour, with black bands and a
• Push the auto-injector firmly against the yellow-ish underbelly – its tail is also paddle-like,
thigh and hold it for several seconds. making it an adept swimmer.

Snake Bites
• A snake injects its poison into a person’s skin and
muscles with its fangs.

Equatorial Spitting Cobra
• this snake will raise a third of itself in an upright
position and display its hood, letting off a loud hiss.
If the cobra still feels threatened then its next step
will be to spray venom, or even strike. A bite from
this snake can often be fatal.
Lake Taal Snake
• This rare species of venomous sea snake can
only be located in Lake Taal and is one of only two
known sea snakes which can only be found in
freshwater
Palawan LongGlanded Coral Snake
• Long-Glanded Coral Snakes have some of the
most unique venom in the world, resulting in an
immediate shock to the system, causing spasms
and an overload of the nervous system.
Philippine Cobra
• Its ability to spit venom up to 3 metres with
precision accuracy makes this the most feared
snake in the Philippines. This deadly, spitting cobra
is native to Luzon, Catanduanes, Masbate and
Mindoro but sightings have also been reported on
some of the neighbouring islands.
• Signs and symptoms
− Immediate pain at the bite site
− Swelling and tenderness around the bite
site
− Fainting (from the emotional shock)
− Sweating
− Nausea and vomiting
− Shock
• The bite of the coral snake delivers a slightly
different poison that may cause these additional
problems:
− Respiratory difficulties
− Slurred speech
 − Paralysis • They are among the most deadly chemicals
− Coma developed.
− Seizures − Small quantities can kill large numbers of
people by causing cardiac arrest within
Treatment for Snake Bites minutes of exposure.
• Keep the patient calm and quiet. • Nerve agents block an essential enzyme in the
• Have the patient lie down and try to relax. nervous system and cause these SLUDGE-like
• Wash the bite area with soap and water. symptoms.
• If the bite occurred on the arm or leg, splint the • Additional symptoms of organophosphate
affected extremity. poisoning include:
• Treat the patient carefully. − Shortness of breath
• Arrange for prompt transport to a hospital with − Slow heart rate
antivenin. − Muscle weakness, twitching, or paralysis
− Slurred speech
Absorbed Poisons − Seizures
• Occurs when a poisonous substance enters the − Loss of consciousness
body through the skin • Four of the most common nerve agents:
• Common absorbed poisons: − Sarin (GB)
− Insecticides − Soman (GD)
− Toxic industrial chemicals − Tabun (GA)
• Signs and symptoms − V agent (VX)
− Traces of powder or liquid on the skin • If you are called to the scene of a nerve agent
− Inflammation or redness of the skin poisoning, keep yourself, rescuers, and bystanders
− Chemical burns from being contaminated.
− Skin rash • A well-trained hazardous materials team in special
− Burning protective equipment is needed to remove and
− Itching decontaminate people.
− Nausea and vomiting • SCBA and encapsulating suits are needed to
− Dizziness prevent exposure to rescuers.
− Shock
Treatment for Nerve Agents
Treatment for Absorbed Poisons • Assess and support the patient’s ABCs.
• Ensure that the patient is no longer in contact with • Nerve agent antidote kits:
the toxic substance. − DuoDote kit: contains one auto-injector
• Brush—do not wash—any dry chemical off the syringe that contains atropine and
patient. pralidoxime chloride
− Contact with water may activate the dry − Mark I kit: contains two auto-injector
chemical and result in a burning reaction. syringes—atropine and pralidoxime chloride
• Wash the patient completely for at least 20
minutes.
• If additional EMS personnel are delayed, contact
the poison control center or your medical director
for additional treatment.
• If the patient is experiencing shock, have the
patient lie down and elevate the legs.
• If the patient is having difficulty breathing,
administer oxygen.
Overview of Substance Abuse
Nerve Agents • Drug abuse: use of drugs that causes harm to the
• Nerve agents can be absorbed through the skin, user or to others affected by the user
inhaled, or injected. • Habituation: psychological dependence on a drug
or drugs
Patient Assessment • Physical dependence
• Toxicologic emergencies are generally considered − More prone to serious illnesses and
medical emergencies. injuries
• General assessment approach is the same for all
patients. • Acute alcohol intoxication
− Establish and maintain the airway.
Scene Size-Up − Give high concentration oxygen.
• Patients who have taken an overdose may be − Assist ventilations as necessary.
dangerous. − Establish vascular access.
− Call for law enforcement or a crisis unit if − Monitor ECG rhythm.
necessary. − Assess blood glucose level.
− Administer thiamine if directed by medical
Primary Assessment control.
• Form a general impression. − Transport to an appropriate facility.
• Identify concerns or life threats.
• Identify MOI or NOI. • Withdrawal seizures
• Identify need for additional resources. − Occur within 12 to 48 hours of last drink
• Set the priority. − Use the same care as for alcohol
intoxication.
History Taking − Consider administering benzodiazepines.
• Use OPQRST and SAMPLE history.
• Obtain the following: • Delirium tremens
− What is the agent? − Usually starts 48 to 82 hours after the last
− When was it ingested, injected, absorbed, drink
or inhaled? − Signs and symptoms may include:
− How much was taken, injected, absorbed, • Tremors
or inhaled? • Diaphoresis
− What else was taken? • Hallucinations
− Has the patient vomited or aspirated? • Hypotension
− Why was the substance taken? − Try to keep the patient calm.
− Administer supplemental oxygen by nasal
Emergency Medical Care cannula.
• Ensure scene safety. − Establish vascular access.
• Maintain the airway. − Check breath sounds.
• Ensure that breathing is adequate. − Maintain an ongoing dialogue.
• Ensure that circulation is not compromised.
• Administer high-concentration oxygen. Stimulants
• Establish vascular access. • Users may become addicted within days.
• Be prepared to manage shock, coma, seizures, − Success of overcoming addiction is low.
and dysrhythmias. − May be taken orally, smoked, or injected
• Transport the patient as soon as possible. − Clinical presentation may include:
• Excitement
Alcohol • Delirium
• Most widely abused drug in the United States • Dilated pupils
• Red flags may include:
− Drinking alone or in “secret” Cocaine
− Loss of memory or “blackouts” • Alkaloid extracted from Erythroxylon coca
− “Green tongue syndrome” • Pathophysiology
Alcohol − A local anesthetic and a CNS stimulant
• Pathophysiology − Quickly absorbed across mucosal
− Evolves through two distinct phases: membranes
• Problem drinking
 − Crack cocaine: cocaine mixed with baking
soda and water that is cooked or baked • Pathophysiology
− Effects are felt between 8 seconds to 1 − Psychoactive ingredient: delta 9-
minute. tetrahydrocannabinol
− When the effects wear off, the user − Usually smoked, but can be ingested
experiences a “crash.” − Signs and symptoms may include:
− Speedballing: use of heroin and cocaine • Euphoria
• Decreased short-term memory
Cocaine • Bloodshot eyes
• Assessment • Assessment and management
− Can cause serious complications, − Focus on supportive care.
including: • Spice
• Lethal ECG dysrhythmias − A blend of synthetic cannibinoids
• Acute myocardial infarction − Can make people delirious
• Pneumomediastinum
Hallucinogens
Amphetamine, Methamphetamine, and • Causes some distortion of sense perception
Amphetamine-like Drugs − Experience is affected by:
• Amphetamines include: • User’s previous drug experience
− Methamphetamine • Dose taken
− Methylenedioxyamphetamine • User’s expectations
− Methylenedioxymethamphetamine • Social setting
• Have a number of clinical applications • Classified as synthetic or naturally occurring
• Methamphetamine
− Low-cost, long-acting (up to 12 hours) LSD
− Ingredients are available locally • Pathophysiology
− Patient management is the same as for − Primarily affects the senses
cocaine. − Physiologic effects may include:
• Mild tachycardia
Management of Stimulant Abuse • Mild hypertension
• Establish and maintain the airway. • Dilated pupils
• Give high-concentration oxygen. • Assessment and management
• Establish vascular access. − Treatment is primarily supportive.
• Apply the ECG monitor, pulse oximeter, and − Limit sensory stimulation as much as
capnometer. possible.
• Administer benzodiazepines per protocol.
• Manage hypotension with serial fluid infusions. Ketamine
• Consider nitroprusside for hypertension. • Pathophysiology
• Consider haloperidol for violent behavior. − Typical oral dosing is 75–300 mg.
• Transport to the appropriate facility. − At higher doses, user may have:
• Follow protocols regarding beta blockers. • Pronounced nausea
• Apply ice packs to reduce hyperthermia. • Difficulty moving
• Maintain urine output. • Complaint of “entering another
• Administer benzodiazepines for seizure. reality”
• Neuromuscular blockade may be needed.
• Assessment and management
Marijuana and Cannabis Compounds − Secure the patient well.
• Derived from Cannabis sativa − Assess and manage ABCs.
• Clinical uses: − Provide oxygen therapy.
− Treatment of glaucoma − Establish vascular access.
− Relief of nausea and appetite loss from − Provide safe transport.
chemotherapy
Peyote and Mescaline
• Pathophysiology
− Profound vomiting often occurs.
− Symptoms include:
• Dilated pupils
• Increased pulse rate
• Mild hypertension
• Increased body temperature
• Assessment and management
− Pay attention to the ABCs.
− Administer supplemental oxygen.
− Monitor vital signs.
− Provide psychological support.
− Arrange safe transport.
Psilocybin Mushrooms
• Typical dose: 2–4 mushrooms
• Pathophysiology
− Onset: 30 minutes
− Effects last 4–6 hours.
− Symptoms may include:
• Vomiting
• Mydriasis
• Mild tachycardia
• Assessment and management
− Pay attention to ABCs.
− Monitor vital signs.
− Safely transport.
− Establish vascular access.
Sedative and Hypnotics
• Sedative: reduce anxiety and calm agitation
• Hypnotic: used as sleeping aids
• Function as CNS depressants
• General incoordination
• Management
− Assess and manage the airway.
− Administer high-concentration oxygen.
− Establish vascular access.
− Apply ECG monitor, pulse oximeter, and
capnometer.
− Consider administering flumazenil.
− Transport to appropriate facility.
Carbon Monoxide
• Pathophysiology
− Colorless, odorless, tasteless gas
− Displaces oxygen, preventing oxygen to
tissues
• Suffocation at the cellular level
• Assessment
− Signs and symptoms are variable and
vague.
− Physical examination may reveal:
• Bounding pulses
• Dilated pupils
• Pallor or cyanosis
• Cherry red color of the skin
• Management
− Provide the highest concentration of
oxygen.
− Remove the patient from the environment.
− Establish and maintain the airway.
− Give high-flow supplemental oxygen.
− Keep the patient quiet and at rest.
− Monitor the ECG rhythm and LOC.
− Transport to the appropriate facility.

Benzodiazepines Chlorine Gas

• Pathophysiology • Chlorine compounds are commonly used in the
− Stimulate the gamma-aminobutyric acid home and in occupational settings.
pathways, resulting in: • Pathophysiology
• Sedation − Minor exposure may include:
• Reduced anxiety • Burning sensation in eyes, nose, and throat
• Relaxation of striated muscle • Slight cough
− Severe exposure may include:
• Assessment • Cyanosis
− Single-entity overdose has low morbidity • Shock
rate • Seizures
− Common clinical effects may include:
• Altered mentation • Assessment and management
• Drowsiness − Remove all patients from the area and
• Slurred speech triage.
 − Deliver high-concentration humidified
oxygen.
− Irrigate burning or itching eyes and skin.
Cyanide
• Pathophysiology
− Rapid-acting and deadly poison
− Combines with cytochrome oxidase,
which blocks utilization of oxygen at the
cellular level
• Death within minutes to an hour if ingested
• Assessment
− Patient may have an altered mental
status.
− Signs and symptoms may include:
• Palpitations
• Odor of almonds on the breath
• Rapid respirations and pulses
• Bright red venous blood and body
• Management
− Should be treated as fast as possible
− If cyanide was inhaled:
• Remove the patient from the
source.
• Establish an airway.
• Administer 100% supplemental
oxygen.
• Assist ventilations as needed.
− Use the cyanide antidote kit.
− If unavailable, break amyl nitrite into
gauze pad.
• Hold over the patient’s nose for about 20 seconds
• Allow the patient to breathe a high concentration
of oxygen for about 40 seconds.
• Hydroxocobalamin
− A safe alternative or adjunct to traditional
treatment
− Included in the “Cyanokit”
− Allergy/anaphylaxis is the primary
concern.
• Methylene blue
− An antidote used to treat
methemoglobinemia
− Methemoglobinemia: alteration of
hemoglobin
• Induced by amyl nitrite and sodium nitrite
− Administered under the guidance of an
expert
Common Household Items
• May include:
− House plants
− Pesticides and herbicides
− Hydrocarbon products
− Glue
− Cleaning agents
Drugs That Increase Sexual Gratification
• Sildenafil (Viagra)
− For hypotension, administer normal saline.
− For cardiac arrest, follow local protocols.
• Marijuana
− Supportive care is indicated.
• Cocaine and other stimulant drugs
− Administer serial boluses of normal saline.
• Amyl nitrite
− Hypotension may result.
• Ecstasy
Drugs Used to Facilitate Sexual Assault
• GHB (Gamma-hydroxybutyrate)
− Odorless and colorless liquid, with a salty taste
− Exerts its effects within 30 to 60 minutes
− Can produce a hypnotic effect
Food Poisoning
• When you encounter two or more people sick at
the same time and at the same scene, think food
poisoning or CO poisoning.
• Pathophysiology
− Toxins that produce food-related deaths:
• Salmonella
• Listeria
• Toxoplasma
• Assessment
− Onset of signs and symptoms can range
from several hours to days or weeks.
− Gastrointestinal complaints are the most
common.
− Respiratory distress or arrest can occur.
• Management
− Establish the airway and vascular access.
− Administer normal saline for hypotension.
− Consider diphenhydramine for facial
flushing.
− Transport to an appropriate facility.