How to Treat Poisoning & Overdose Emergencies

Learn How EMTs & Paramedics Identify, Treat and Care for Patients with Poisoning and Overdose Emergencies

Poisoning and overdose are among the top 10 most common emergencies that EMS professionals respond to, accounting for 3.5% of all EMS calls.

(Click here for our list of the most common EMS Emergencies for EMTs and Paramedics).

According to the Centers for Disease Control and Prevention (CDC), unintentional poisoning (including overdose) is the leading cause of injury death for all age groups. In 2008, unintentional poisoning surpassed motor vehicle traffic fatalities as the leading cause of injury death in the U.S. In 2016, there were 64,070 cases of death due to drug overdose in the U.S. The majority of those cases, approximately 66%, involved an opioid. This figure, which includes prescription opioids and heroin use, is five times higher than the number of opioid overdose deaths reported in 1999. The continuous rise in prescribing, use, and abuse of opioid drugs and increased opioid-related deaths has been termed the opioid epidemic.

Poisoning and Overdose Definition

What Is Poisoning and Overdose?

Poisoning occurs when a person takes or is exposed to a substance that is harmful to their health or can cause death. This can include drugs and drug overdose. Despite child-resistant packaging and dose-limits per container, poisoning is still a major hazard to both children and adults.

According to the National Capital Poison Center, in 2019, most poisonings (76.6%) were unintentional, 18.9% were intentional, and 2.6% were adverse reactions. In children younger than six years, 99.2% of poisonings are unintentional, compared to only 33.8% of teen exposures and 60.8% of adult poisonings.

Overdose is a type of poisoning where a person takes too much of any drug, whether it’s prescription, over-the-counter, legal, or illegal. The severity of an overdose depends on the drug, the amount taken, and the physical and medical history of the person who has overdosed.

Acute poisoning is exposure to poison once for a short period of time. Symptoms develop depending on the degree of exposure.

Systemic poisoning is poison circulating throughout the body, usually after absorption. (In contrast, substances that destroy tissue but do not absorb into the bloodstream, such as lye, are considered corrosives rather than poisons.) Many common household medications are not labeled with a skull-and-crossbones image, even though they can cause severe illness or even death.

Chronic poisoning is long-term repeated or continuous exposure to a poison where symptoms do not occur immediately or after each exposure. The patient gradually becomes ill or becomes ill after a long period. Chronic poisoning most commonly occurs after exposure to poisons that bioaccumulate or gradually accumulate in the body over time. Poisons such as mercury, gadolinium, and lead bioaccumulate.

Most biocides, including pesticides, act as poisons to target organisms, although less observable chronic poisoning can also occur in non-target organisms, such as the people who apply the biocides.

Many substances regarded as poisons are only toxic indirectly by toxication. For example, “wood alcohol” or menthol is not a poison by itself but is chemically converted to toxic formaldehyde and formic acid in the liver. Many drug molecules are made toxic in the liver, and the genetic variability of certain liver enzymes makes the toxicity of many compounds differ between individuals.

Poisoning should not be confused with envenomation, which is when an animal injects venom into a person. Venom is a specialized type of poison that requires the victim to be wounded for the venom to enter the bloodstream. Ultimately, the most effective treatment for venom is the right antivenom.

Risk Factors for Drug Overdose

 

Improper storage of drugs: Improperly stored drugs can be easy targets for small children, who are curious and tend to put things in their mouth. It’s easy for children to get into and accidentally overdose on drugs that aren’t properly sealed and stored away from them.

Not knowing or following dosage instructions: Even adults can overdose on medication if they don’t follow the instructions. Accidentally taking too much or taking your doses sooner than directed can easily lead to an overdose of an otherwise safe drug for you.

History of misuse or addiction: Intentionally misusing prescription drugs or using illicit drugs can put you at risk of a drug overdose, mainly if it happens often or if you become addicted. This risk increases if you use multiple drugs, mix different drugs, or use them with alcohol.

History of mental disorders: Mental disorders can also be risk factors for a drug overdose. Depression and suicidal thoughts can be overdose triggers, especially if these symptoms are not being treated.

Signs and Symptoms of Poisoning

The effects of poisoning depend on the substance, amount, and type of contact. Your age, weight, and state of health also affect your symptoms.

The following are common signs and symptoms of poisoning:

• Nausea and vomiting
• Diarrhea
• Rash
• Redness or sores around the mouth
• Dry mouth
• Drooling or foaming at the mouth
• Trouble breathing
• Dilated pupils (bigger than normal) or constricted pupils (smaller than normal)
• Confusion
• Fainting
• Shaking or seizures

Signs and Symptoms of Drug Overdose

The symptoms of a drug overdose may vary depending on the person, drug, and amount taken. However, universal symptoms of overdose include:

• Nausea and vomiting
• Drowsiness
• Loss of consciousness
• Trouble breathing
• Difficulty walking
• Agitation
• Aggression or violence
• Enlarged pupils
• Tremors
• Convulsions
• Hallucinations or delusions

Causes of Poisonings and Overdoses

Most Common Sources of Pediatric (<6 Years Old) Poisonings

• Cosmetic & Personal Care Products
• Cleaning Substances
• Analgesics
• Foreign Bodies/Toys/Miscellaneous
• Dietary Supplements/Herbals/Homeopathic
• Antihistamines
• Topical Preparations
• Vitamins
• Pesticides
• Plants

Most Common Sources of Adult (≥20 Years Old) Poisonings

• Analgesics
• Sedative/Hypnotics/Antipsychotics
• Antidepressants
• Cardiovascular Drugs
• Cleaning Substances (Household)
• Alcohols
• Anticonvulsants
• Antihistamines
• Pesticides
• Hormones and Hormone Agonists

When to Call 911 for Poisonings

If you suspect that someone has been exposed to poison or has overdosed, you need to act quickly. If it seems like a severe or life-threatening condition, call 911 for emergency medical treatment immediately. Otherwise, you can call poison control at 1-800-222-1222, and they can provide information and assistance.

If you don’t know what substance is involved, call 911. Here are some tips to help inform the 911 dispatcher:

• Look for signs to identify the poison: spills, odors, stains, changes in behavior, empty containers.
• Bring the bottle or container to the phone with you.
• Look in the victim’s mouth for tablets, powder, discoloration, cuts, burns, or odors.
• Rinse out and wipe a child’s mouth. Keep the poisoned child within sight. You will be asked some questions about the child’s appearance and behavior.

What to tell the 911 dispatcher

If possible, gather the following information for the 911 dispatcher:

• Substance and label information
• Victim’s age and weight
• Existing health conditions or problems
• First aid already given
• Whether or not the person has vomited.
• Your location and distance to the nearest hospital.
• How the substance entered the body (inhalation, swallowing, absorbed through the skin, etc.).

How to Treat Poisonings

Guidelines for treating various types of poisoning are provided below:

For poisons taken internally (swallowed):

• Look into the victim’s mouth and remove all tablets, powder, or any material that is present.
• Examine the mouth for cuts, burns, swelling, unusual coloring, or odor.
• Rinse and wipe out the mouth with a cloth.
• Call 911 and follow the dispatcher’s advice.

For poisons on the skin:

• Brush off all dry poisons and flood-involved parts with large amounts of plain water.
• Wash the skin with bar soap and water and rinse.
• Remove and throw away all affected clothing.
• If you suspect a serious medical condition, call 911 immediately. Information is also available from poison control at 1-800-222-1222.

For poisons in the eye:

• Hold eyelid open and drip room temperature water or normal saline over the bridge of the nose for a full 15 minutes.
• If the victim is a small child, wrap them in a towel (arms placed at sides under the towel) and place the child on a flat surface or in a chair so you can control the child safely.
• Do not try to hold a child under the faucet or in the shower or tub. You should not use water under pressure.
• Do not allow the victim to rub his/her eyes. Do not use medicated drops, such as Visine.
• If you suspect a serious medical condition, call 911 immediately. Information is also available from poison control at 1-800-222-1222.

How Do EMTs & Paramedics Treat Poisonings and Overdose

In the event of a poisoning or overdose emergency, an EMT or paramedic will likely be the first healthcare provider to assess and treat your condition.

EMTs have a clear set of protocols and procedures they must follow for most of the 911 emergencies they encounter. For all suspected poisonings, the first step is a rapid and systematic assessment of the patient. For this assessment, most EMS providers will use the ABCDE approach.

ABCDE stands for Airway, Breathing, Circulation, Disability, and Exposure. The ABCDE approach is applicable in all clinical emergencies for immediate assessment and treatment. It can be used in the street with or without any equipment. It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals, or intensive care units.

Treatment Guidelines & Resources for Medical First Responders

Treatment guidelines for poisoning and overdose can be found on page 225 of the National Model EMS Clinical Guidelines by the National Association of State EMT Officials (NASEMSO). NASEMSO maintains these guidelines to facilitate state and local EMS system clinical guidelines, protocols, and operating procedures. These guidelines are either evidence-based or consensus-based and have been formatted for use by EMS professionals.

The guidelines include the following assessment:

1. Make sure the scene is safe. Use environmental Carbon Monoxide (CO) detector on “first in” bag if possible
2. Consider body substance isolation (BSI) or appropriate PPE (PPE)
3. Assess ABCD and, if indicated, expose patient for assessment, and then re-cover to assure retention of body heat
4. Vital signs including temperature
5. Attach a cardiac monitor and examine rhythm strip for arrhythmias (consider 12-lead EKG)
6. Check blood glucose level
7. Monitor pulse oximetry and ETCO2 for respiratory decompensation
8. Perform carboxyhemoglobin device assessment, if available
9. When indicated, identify specific medication taken (including immediate release vs. sustained release), time of ingestion, dose, and quantity. When appropriate, bring all medications (prescribed and not prescribed) in the environment
10. Obtain an accurate ingestion history (as the patient may become unconscious before arrival at ED):
    • Time of ingestion
    • Route of exposure
    • Quantity of medication or toxin taken (safely collect all possible medications or agents)
    • Alcohol or other intoxicant taken
11. If bringing in an exposure agent, consider the threat to yourself and the destination facility
12. Obtain pertinent cardiovascular history and other prescribed medications
13. Check for needle marks, paraphernalia, bites, bottles, or evidence of agent involved in the exposure, self-inflicted injury, or trauma
14. Law enforcement should have checked for weapons and drugs, but you may decide to re-check
15. Obtain pertinent patient history
16. Perform physical examination

EMS Protocol for Poisoning and Overdose Emergencies

Protocols for prehospital treatment of poisoning and overdose vary by EMS provider and can also depend on the patient’s symptoms or medical history.

Below is an example prehospital treatment protocol for poisoning and overdose:

1. Perform Initial Treatment / Universal Patient Care Protocol
2. Routes:
   • Ingested Poisons:
     • Protect airway.
     • DO NOT induce vomiting.
     • Transport the patient with all containers, bottles, and labels from the substance, if safe to do so.
   • Inhaled Poisons:
     • Immediate removal from the hazardous environment.
     • Maintain airway and support respirations.
     • Transport the patient with all containers, bottles, and labels from the substance, if safe to do so.
   • Absorbed Poisons:
     • Remove the poison using procedures described in Burn Protocol.
     • Transport the patient with all containers, bottles, and labels from the substance, if safe to do so.
   • Injected Poisons:
     • See treatment guidelines for specific substances.
3. After decontamination procedures have been completed, do not delay transport.
4. Determine the following:
   • What?
   • When?
   • How much?
   • Over what period of time?
   • Were any actions taken by bystanders, family members, and patient prior to EMS arrival?
5. Overdose / Toxic Ingestion / Poisoning Emergencies:
   • Alcohol:
     • Emergencies involving alcohol can range from acute intoxication to alcohol withdrawal and delirium tremens (DT’s).
     • Assess the patient and follow the proper protocol for medical management based on clinical presentation.
       • Consider hypoglycemia. Perform rapid glucose determination. If glucose <60 mg/dL or clinical signs and symptoms indicate hypoglycemia, refer to the Diabetic Emergencies Protocol.
       • For signs and symptoms of hypovolemic shock or dehydration, follow the Hypoperfusion Shock Protocol.
       • For seizures due to alcohol withdrawal, refer to the Seizures Protocol.
   • Narcotics / Opiates:
     • Support respirations, as necessary, with a BVM and supplemental O2. Defer consideration of advanced airway management until after administration of Naloxone if BVM ventilation is adequate.
     • Consider hypoglycemia. Perform rapid glucose determination. If glucose is <60 mg/dL or clinical signs and symptoms indicate hypoglycemia, refer to the Diabetic Emergencies Protocol.
     • For a suspected narcotic overdose complicated by respiratory depression:
       • Administer Naloxone (Narcan^®) 1 mg IM (Anterior Lateral Thigh). If the patient does not show signs of improvement (adequate respiratory response/increased LOC), administer an additional 1 mg IM in 10 minutes.
       • If unable to administer Naloxone IM, administer 2 mg intranasal (IN) via atomizer. If the patient does not show signs of improvement (adequate respiratory response/increased LOC), administer an additional 2 mg IN and request ALS backup.
   • Tricyclic Antidepressants:
     • Support respirations, as necessary, with a BVM and supplemental O2. (Tricyclic Antidepressants include: Amitriptyline (Elavil^®), Doxepin (Sinequan^®, Adepin^®), Imipramine (Tofranil^®).
   • Cholinergic:
     • Support respirations, as necessary, with a BVM and supplemental O2. (Pesticides (Organophosphates, Carbamates) and nerve gas agents (Sarin, Soman) are the most common exposures.
   • Calcium Channel Blockers:
     • Support respirations, as necessary, with a BVM and supplemental O2.
   • Beta-Blockers:
     • Administer oxygen via non-rebreather mask at 12–15 lpm, as necessary—support respirations with a BVM.
   • Stimulants:
     • Assess the patient and follow the proper protocol for medical management based on clinical presentation.
     • Support respirations, as necessary, with a BVM and supplemental O2.
     • Serious signs and symptoms (seizures, tachydysrhythmias):
       • For patients that are severely agitated or combative follow the Behavioral Emergencies Protocol.

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