# Overdose Scenario



## rhan101277 (Jul 14, 2008)

You and your partner are dispatched to a scene, where you find a 8 year old whose mother says he has taken a whole container of aspirin thinking it was candy.  You see the aspirin bottle and pills gone.  What to do you do?

A. Don't administer charcoal because it has no effect on aspirin.

B. Blindfold the patient then have him/her drink it.

C. Direct patient to close their eyes and hold their nose and chug.

D. Call medical control, administer charcoal in foam up with straw.

E. Call poison control to get directions on what to do.


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## mikeylikesit (Jul 14, 2008)

C. because i will not blindfold a child then tell them to drink something that i would not want to drink. i want to keep the child's trust. i would call med control to see if multiple doses of charcoal can be administered. i read quite a few studies that say more than one does of charcoal can be more effective. i have only read one study that say's that multi-doses aren't efficient.


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## rhan101277 (Jul 14, 2008)

Thanks 10chars


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## akflightmedic (Jul 14, 2008)

rhan101277 said:


> You and your partner are dispatched to a scene, where you find a 8 year old whose mother says he has taken a whole container of aspirin thinking it was candy.  You see the aspirin bottle and pills gone.  What to do you do?
> 
> A. Don't administer charcoal because it has no effect on aspirin.
> 
> ...




A is incorrect information.

B I hope you posted this only to be remotely funny (which you did not suceed IMO)
   You better NEVER EVER blindfold a patient and ask for "blind trust" which you will   completely destroy and lose forever.

C This may come into play. After all we are tallking about an 8 year old. They are smart and know the deal. However no 8 year old I know would mistake ASA for candy and they certainly wouldnt make it past chewing up the first one (have you ever chewed ASA, I have)

D is a possibility depending on your area

E is another possibillity depending on your area




Mikey, you have any links to this study you mentioned? Or is it the one referred to in Wikipedia??

Anyways, here is some information courtesy of wikipedia as well. It seems spot on so I do not mind sharing, but I would like to see the study referenced unless it is the one from wikipedia as I already saw that one.

Ultimately, if enough is taken, you are most likely in for a long treatment course, typically ending up with some hemo dialysis.

I am sure Rid or Vent may have much more valid, relevant input shortly as admittedly I have not had an ASA overdose in several years.

Overdose
Aspirin overdose can be acute or chronic. In acute poisoning, a single large dose is taken; in chronic poisoning, supratherapeutic doses are taken over a period of time. Acute overdose has a mortality rate of 2%. Chronic overdose is more commonly lethal with a mortality rate of 25%; chronic overdose may be especially severe in children.[83]


[edit] Symptoms
Aspirin overdose has potentially serious consequences, sometimes leading to significant morbidity and mortality. Patients with mild intoxication frequently have nausea and vomiting, abdominal pain, lethargy, tinnitus, and dizziness. More significant symptoms occur in more severe poisonings and include hyperthermia, tachypnea, respiratory alkalosis, metabolic acidosis, hyperkalemia, hypoglycemia, hallucinations, confusion, seizure, cerebral edema, and coma. The most common cause of death following an aspirin overdose is cardiopulmonary arrest usually due to pulmonary edema.[84]


[edit] Toxicity
The acutely toxic dose of aspirin is generally considered greater than 150 mg per kg of body mass.[55] Moderate toxicity occurs at doses up to 300 mg/kg, severe toxicity occurs between 300 to 500 mg/kg, and a potentially lethal dose is greater than 500 mg/kg.[85] This is the equivalent of many dozens of the common 325 mg tablets, depending on body weight. Chronic toxicity may occur following doses of 100 mg/kg per day for two or more days.[85]


[edit] Treatment
All overdose patients should be conveyed to a hospital for assessment immediately. Initial treatment of an acute overdose includes gastric decontamination. This is achieved by administering activated charcoal, which adsorbs the aspirin in the gastrointestinal tract. Stomach pumps are no longer routinely used in the treatment of poisonings but are sometimes considered if the patient has ingested a potentially lethal amount less than 1 hour previously.[86] Inducing emesis with syrup of ipecac is not recommended.[55] Repeated doses of charcoal have been proposed to be beneficial in aspirin overdose;[87] although, one study found that repeat dose charcoal might not be of significant value.[88] However, most clinical toxicologists will administer additional charcoal if serum salicylate levels are increasing.

Patients are monitored until their peak salicylate blood level has been determined.[57] Blood levels are usually assessed four hours after ingestion and then every two hours after that to determine the maximum level. Maximum levels can be used as a guide to toxic effects expected.[89]

There is no antidote to salicylate poisoning. Monitoring of biochemical parameters such as electrolytes, liver and kidney function, urinalysis, and complete blood count is undertaken along with frequent checking of salicylate and blood sugar levels. Arterial blood gas assessments are performed to test for respiratory alkalosis and metabolic acidosis. Patients are monitored and often treated according to their individual symptoms, patients may be given intravenous potassium chloride to counteract hypokalemia, glucose to restore blood sugar levels, benzodiazepines for any seizure activity, fluids for dehydration, and importantly sodium bicarbonate to restore the blood's sensitive pH balance. Sodium bicarbonate also has the effect of increasing the pH of urine, which in turn increases the elimination of salicylate. Additionally, hemodialysis can be implemented to enhance the removal of salicylate from the blood. Hemodialysis is usually used in severely poisoned patients; for example, patients with significantly high salicylate blood levels, significant neurotoxicity (agitation, coma, convulsions), renal failure, pulmonary edema, or cardiovascular instability are hemodialyzed.[57] Hemodialysis also has the advantage of restoring electrolyte and acid-base abnormalities while removing salicylate;[57] hemodialysis is often life-saving in severely ill patients.


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## mdkemt (Jul 14, 2008)

Plain and simple...Give activated charcoal!  This is what our protocols state and our training has told us to do.  Really this child would need a gastric flush.  I would call medical control pending on how far I am from the hospital.  Where I work now I would get the nurse to because we are a 2-5min drive away from the hospital and still give activated charcoal!

MDKEMT


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## mikeylikesit (Jul 14, 2008)

akflightmedic said:


> A is incorrect information.
> 
> B I hope you posted this only to be remotely funny (which you did not suceed IMO)
> You better NEVER EVER blindfold a patient and ask for "blind trust" which you will completely destroy and lose forever.
> ...


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## BossyCow (Jul 14, 2008)

I'd be a bit concerned about a child of that age thinking aspirin was candy as well. By that age, most kids are pretty good at determining what's candy and what itsn't. 

Whole bottle? How many were in the bottle? New Bottle? Old Bottle? Did the kid actually eat what is assumed he ate? I'd also be looking at a possible intentional overdose with the psych implications of that.


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## NC-EMT08 (Jul 14, 2008)

We no longer carry activated charcoal on the county trucks in my area.  I don't know why...  We are pretty much always within 20min transport time of a hospital, but it still seems like that time could make a big difference in the case of an overdose.

Assuming that you are allowed and able to administer charcoal, I would think that D would be the correct thing to do.


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## rhan101277 (Jul 14, 2008)

This was a question from EMT-B exam review.  I was just curious about the toughness of the exam, this review was 1500 questions.  Wonder how they break it down to 100.  I answered wrong, I answered have them pinch nose, close eyes and drink.  That blindfold answer is actually in the text.


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## WuLabsWuTecH (Jul 14, 2008)

We were taught to use an opaque straw and opaque cup, and tell the child it'll taste bad.  On of the instructors also suggessted telling the mom to say she' take him ot get ice cream later or something to incecitize it even more.

While we don't have to contract med. control to use charcoal (for basics in my state), it is still advisable to do so when unsure.  We'll let him contact poison control center if he thinks he needs to do so.

My answer is D.


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## KEVD18 (Jul 23, 2008)

act. charcoal recently went from standing orders to a med control option in ma, meaning we need orders for it. 

my first question would be how long ago was the supposed ingestion. anything >45min, im not going to bother, since its already passed through the stomach and into the lower gi tract.

my next thought would be whats the tx time to the receiving er. <10min, which is average for my service area, im probably going to hold off. it has been my experience in the few times that i have administered ac orally that it doesnt stay down long enough to absorb anything. also, the patients i have given it too never get the whole dose down. but if im 6min from the er, they can drop an ng tube and administer the drug without most(if not all) of the complications.

every single time, without exception, i have administered activated charcoal po the back of my truck has ended up with a holstein motif in <2min.


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## SCFD8REZ (Jul 30, 2008)

If you are an emt-b call poison control and they will tell you  the facts stats and lethal dosage aording to the childs weight  and exactly what to do, this is what we are taught anyway. If you have emt-p's in your department or amr medic is on scene chances are they have more jurisdiction then you as well as knowledge and they will probably know what to do. I dont think that activated charcoal would be the way to go here, i think ipecac would get it out of there stomache if it was needed and asprin is not a corrosive so why not?


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## mycrofft (Jul 30, 2008)

*My ususal sideline potshots*

1. "Thought it was candy"...most probably pediatric or baby ASA if it tasted like candy. Bring the bottle so they can approximate milligrammage.
2. Has anyone personally seen a patient, especially a kid, actually voluntarily drink a whole dose of charcoal solution? My E.R. experience was that we always skipped the thirty minutes of cajoling and went for the NG tube. (For that matter, how about the "twenty minutes' eyewash"?).
3. How long ago? Meal before? Homemade tx/rx attempted (like baking soda, Tums, vomiting, laxatives, milk , eggwhites, etc?).
4. For that matter, I've been out of circulation so to speak, I'm not hearing about ipecac here. Is it still in the armamentorium?

Good deal it wasn't APAP (acetaminophen).


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## mycrofft (Jul 30, 2008)

*HA! my comment took so long to post someone mentioned ipecac!*

My dumb question, but is the LD50 of use here when the tx is going to be empirical in the field (bring the container and information, try to disgorge any remaining tabs and neutralize any remainder )while boogeying to definitive care.


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## reaper (Jul 30, 2008)

Mycrofft is right. How many have ever given charcoal before? You can barley get an adult to drink it voluntarily. I have never gotten a kid to take it voluntarily. That is why the ED will use a NG tube to administer it.

Ipecac has been taken off our units and they are talking about taking charcoal off to. We rarely ever use it.


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## fma08 (Jul 30, 2008)

Seen it used maybe 3-4 times  in a year in the field (most of them as a teachable moment, and none were kids). The other times in clinicals, they did the NG tube route. Ipecac was just taken off of our rigs too.


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## MedicPrincess (Jul 31, 2008)

From our protocols on Activated Charcoal..We don't actually have a protocol for administration of Activated Charcoal for a Pediatric patient.  It would be one of the few times we would have to call Med Control for Medication Orders.  But notice the WILLING/COOPERATIVE statement.  Also, 95% of my transports are less than 15 minutes to an ER.  An 8 year old would go to the Childrens Hospital about 20 minutes.

_If ingestion is suspected with unknown substance and there is no altered mental status and caustic ingestion can be ruled out, if patient is willing/cooperative; place patient in Fowler’s position and administer *Activated Charcoal* 50 – 100 grams po. If the timing of the ingestion has been less than an hour of EMS’s arrival, hold off giving the charcoal until you discuss with medical control as some physicians may instead, choose to lavage the patient on arrival to the emergency department _


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## Ridryder911 (Jul 31, 2008)

Activated charcoal is no good unless you can administer activated charcoal with sorbitol to allow expulsion/defecation removal. 

I used to routinely place NG tubes in those with overdoses however; recent literature has demonstrated that most "medications" & overdoses are not affected by evacuation through NG tube especially if the incidence occurred > 30 minutes. 

The only time I place NG tubes is on tricyclic overdoses, and some other similar med.'s. I no longer routinely place them or (Code 3 oral gastric lavage). I will allow the patient to drink activated charcoal (works well mixed with chocolate milk). 

R/r 911


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## mdkemt (Jul 31, 2008)

Ridryder911 said:


> Activated charcoal is no good unless you can administer activated charcoal with sorbitol to allow expulsion/defecation removal.
> 
> I used to routinely place NG tubes in those with overdoses however; recent literature has demonstrated that most "medications" & overdoses are not affected by evacuation through NG tube especially if the incidence occurred > 30 minutes.
> 
> ...



Nice post Rid!  Good advice.  I haven't seen any of that literature yet.  Do you have a link I can check out?

MDKEMT


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## mikeylikesit (Jul 31, 2008)

Ridryder911 said:


> I will allow the patient to drink activated charcoal (works well mixed with chocolate milk).
> 
> R/r 911


 LOL, i did it with chocolate milk once...didn't work and i had a mess all over the back of the bus to clean up...it would have worked if she kept shaking it before she drank it like i told her to so that she didn't get to the bottom and get pure solution.


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