5-141
Cardiovascular Fainting/near fainting, Postural hypotension, Recovery or symptoms of
palpitations, chest shortness of breath on CHF
pain exertion
CNS Hallucinations, dif- Numbness/tingling/ Recovery or symptoms of
culty concentrating, painful sensations, learning disabilities, chronic
headaches, visual visual disturbances pain, long term visual
disturbances disturbances
Objective: Signs
Focus of the initial physical examination should be on ruling out life/limb/sight threatening conditions. In
poisonings these involve the respiratory, cardiovascular, and central nervous systems.
Using Basic Tools: Inspection: Should reveal spontaneous conversation, gait, posture, general appearance,
affect (depressed, agitated, happy) and appearance of the skin (needle track marks or other evidence of drug
use, evidence of trauma, discoloration). Vital signs can indicate type and severity of systemic effects. Monitor
cardiac function. Perform a basic neuro examination with a focus on mental status (assess for agitation,
mania, depression, etc., as well as basic orientation) and eyes (pupil size, equality, and reactivity, nystagmus,
visual acuity, and extraocular muscles). Observe gait if possible and perform tests of cerebellar function (i.e.,
nger-to-nose, rapidly alternating hand movements, heel-to-shin, Romberg).
Signs Acute(< 2 hr) Sub acute (2-48 hr) Chronic (>48 hr)
Respiratory Dyspnea, wheezing, Shortness of Recovery or COPD,
stridor, apnea, breath on exertion restrictive lung disease,
hypo/hyperventilation, emphysema, etc...
Cardiovascular Hypo/hypertension, Signs of ischemia/ Recovery or signs of chronic
tachy/bradyarrhytmias infarction, postural CV disease, i.e. CHF,
hypotension, early CHF cardiomyopathy, recurrent
tachy/bradyarrhythmias
CNS Stroke, seizures, altered Paralysis, seizures Recovery or persisting
mental status to include persistent altered paralysis, recurrent seizures,
coma, agitation/ mental status mental retardation, persistent
somnolence/depression vegetative state
Using Advanced Tools: Pulse oximetry (WARNING: Pulse oximetry may be normal in carbon monoxide
poisoning, cyanide poisoning initially, methemoglobinemia, and other conditions causing inadequate oxygen-
ation of the tissues). The presence of a normal pulse oximetry reading does not always indicate adequate
oxygenation. EKG (arrhythmias). Lab: urinalysis, blood glucose. Drug testing is generally not available in
eld environments.
Assessment:
Differential Diagnosis: See AEIOU-TIPS discussion in Introduction.
Plan:
Treatment
- Secure airway. If patient is hypoxic and/or hypoventilating apply oxygen and assist respirations.
- Start an IV in all presumed poisoned patients for drug access. Fluid resuscitate as needed to support
blood pressure. - Treat arrhythmias per ACLS.
- Decontamination procedures: Decontaminate skin and mucous membranes as required with mild soap and
water. Remove patient from any further exposure to toxic vapors/fumes. Give syrup of Ipecac (if within