Key Takeaways
- Four routes of poisoning exposure: ingestion, inhalation, injection, and absorption (skin/eyes)
- Opioid overdose triad: pinpoint pupils (miosis), respiratory depression, and altered mental status
- Naloxone (Narcan) dose: intranasal 4 mg or intramuscular 0.4-2 mg -- may need to repeat every 2-3 minutes
- Carbon monoxide poisoning causes headache, nausea, confusion -- cherry red skin is a late/unreliable sign; SpO2 readings may be falsely normal
- SLUDGEM mnemonic for organophosphate poisoning: Salivation, Lacrimation, Urination, Defecation, GI distress, Emesis, Miosis
- Hypothermia classifications: mild (90-95 degrees F), moderate (82-90 degrees F), severe (<82 degrees F)
- Heat stroke is a life-threatening emergency with altered mental status and core temp >104 degrees F -- requires aggressive cooling
- Near-drowning: prioritize airway management and ventilation; do NOT attempt to drain water from lungs
Last updated: February 2026
Poisoning, Overdose & Environmental Emergencies
Poisoning, overdose, and environmental emergencies encompass a wide range of conditions. EMTs must be able to identify the type of exposure, recognize toxidromes (toxic syndromes), and provide appropriate treatment.
Routes of Poisoning Exposure
| Route | Examples | EMT Considerations |
|---|---|---|
| Ingestion | Medications, household chemicals, plants, contaminated food | Most common route; do NOT induce vomiting |
| Inhalation | Carbon monoxide, smoke, chemical fumes, gases | Ensure scene safety; remove patient from environment |
| Injection | Snake/insect bites, IV drug use, needle sticks | Look for injection sites; assess for envenomation |
| Absorption | Pesticides, chemical agents, poison ivy/oak | Remove contaminated clothing; irrigate skin |
General Poisoning Management
- Scene safety -- protect yourself from exposure
- Identify the substance if possible (bring container to hospital)
- Contact Poison Control Center: 1-800-222-1222
- Do NOT induce vomiting unless directed by Poison Control
- Manage ABCs and transport
- Bring all pill bottles, containers, or substances found at the scene
Opioid Overdose
The opioid epidemic has made this one of the most common overdose presentations EMTs encounter.
Common Opioids
- Heroin, fentanyl, carfentanil
- Prescription opioids: oxycodone, hydrocodone, morphine, methadone
Opioid Toxidrome (Classic Triad)
- Pinpoint pupils (miosis)
- Respiratory depression (slow, shallow, or absent breathing)
- Altered mental status (unresponsive or severely decreased consciousness)
Naloxone (Narcan) Administration
Naloxone is an opioid antagonist that reverses the effects of opioids.
| Route | Dose | Notes |
|---|---|---|
| Intranasal (IN) | 4 mg (one spray in one nostril) | Preferred prehospital route -- no needles |
| Intramuscular (IM) | 0.4-2 mg | Inject into deltoid or lateral thigh |
| Intravenous (IV) | 0.4-2 mg | ALS intervention |
Key Points:
- May repeat every 2-3 minutes if no response
- Onset: IN ~3-5 minutes, IM ~3-5 minutes, IV ~2 minutes
- Duration of naloxone (30-90 minutes) is shorter than most opioids -- patient may re-sedate
- Provide BVM ventilation while waiting for naloxone to take effect
- Patient may become agitated, combative, or experience withdrawal symptoms upon waking
- Be prepared for vomiting -- have suction ready
Carbon Monoxide (CO) Poisoning
Carbon monoxide is an odorless, colorless gas that binds to hemoglobin with 200-250 times greater affinity than oxygen, forming carboxyhemoglobin (COHb).
Sources
- Furnaces, water heaters, generators
- House fires, car exhaust
- Poorly ventilated spaces with combustion
Signs and Symptoms
- Early: Headache, nausea, dizziness, fatigue (often mistaken for flu)
- Progressive: Confusion, visual changes, chest pain, shortness of breath
- Severe: Seizures, loss of consciousness, cardiac arrest
- Cherry red skin -- classically taught but actually a late and unreliable sign
- SpO2 may read falsely normal (pulse oximeter cannot distinguish COHb from O2Hb)
Treatment
- Remove from exposure (ensure scene safety)
- High-flow oxygen via NRB at 15 L/min -- this is the primary treatment
- Half-life of COHb: ~4-6 hours on room air, ~60-90 minutes on 100% O2
- Transport to facility with hyperbaric oxygen capability if severe
Organophosphate Poisoning
Organophosphates (found in pesticides and nerve agents) inhibit acetylcholinesterase, causing excessive acetylcholine accumulation.
SLUDGEM Mnemonic
| Letter | Sign/Symptom |
|---|---|
| S | Salivation (excessive drooling) |
| L | Lacrimation (tearing) |
| U | Urination (involuntary) |
| D | Defecation (involuntary) |
| G | GI distress (cramping, nausea) |
| E | Emesis (vomiting) |
| M | Miosis (pinpoint pupils) |
Additional Signs
- Bradycardia
- Bronchospasm and bronchorrhea (excessive secretions)
- Muscle fasciculations (twitching)
- Seizures
EMT Treatment
- Decontaminate -- remove clothing, brush off dry chemicals, irrigate with water
- Protect yourself -- wear appropriate PPE (gloves, gown at minimum)
- Manage airway -- suction copious secretions
- High-flow oxygen
- Transport rapidly -- atropine (the antidote) is an ALS/hospital intervention
Hypothermia
Hypothermia occurs when core body temperature falls below 95 degrees F (35 degrees C).
| Severity | Core Temperature | Signs and Symptoms |
|---|---|---|
| Mild | 90-95 degrees F (32-35 degrees C) | Shivering, poor coordination, slurred speech, confusion |
| Moderate | 82-90 degrees F (28-32 degrees C) | Shivering stops, increasing confusion, drowsiness, cardiac dysrhythmias |
| Severe | <82 degrees F (<28 degrees C) | Unresponsive, no shivering, fixed dilated pupils, V-fib risk, appears dead |
Hypothermia Treatment
- Remove from cold environment
- Remove wet clothing and cover with warm blankets
- Handle the patient gently -- rough handling can trigger V-fib in severe hypothermia
- Apply heat to the core (neck, armpits, groin) -- passive external rewarming
- Administer warm, humidified oxygen if available
- Do NOT rub extremities or apply direct heat to arms/legs
- In severe hypothermia: "They're not dead until they're warm and dead" -- continue resuscitation
Hyperthermia
Heat Exhaustion vs. Heat Stroke
| Feature | Heat Exhaustion | Heat Stroke |
|---|---|---|
| Mental status | Normal or mild confusion | Altered (confusion, seizures, coma) |
| Skin | Cool, pale, diaphoretic (sweaty) | Hot, red; may be dry or wet |
| Core temp | <104 degrees F (<40 degrees C) | >104 degrees F (>40 degrees C) |
| Severity | Urgent | Life-threatening emergency |
Heat Stroke Treatment
- Aggressive cooling is the priority
- Move to cool environment, remove excess clothing
- Apply cold packs to neck, armpits, groin (areas with large blood vessels)
- Fan the patient while misting with water
- Cold IV fluids (ALS)
- Rapid transport
Drowning
- Remove from water (ensure rescuer safety)
- C-spine precautions if diving injury suspected
- Priority is ventilation -- begin rescue breathing/BVM immediately
- Do NOT attempt to drain water from lungs (abdominal thrusts are not effective)
- Even if patient appears to recover, transport for observation (risk of delayed pulmonary edema)
Bites and Stings
Snake Bites
- Keep patient calm and still (reduces venom spread)
- Immobilize the affected extremity at or below heart level
- Mark the edge of swelling with a pen and note the time
- Do NOT apply a tourniquet, ice, or attempt to suck out venom
- Transport to facility with antivenom capability
Spider Bites
- Black widow: Severe muscle pain, abdominal rigidity, hypertension
- Brown recluse: Initially painless, develops into necrotic wound over hours/days
- Treatment: Clean wound, ice, pain management, transport
Marine Envenomation
- Jellyfish: rinse with vinegar (acetic acid), remove tentacles with tweezers
- Do NOT rinse with fresh water (can cause nematocyst discharge)
Test Your Knowledge
An unresponsive patient is found with a respiratory rate of 4, pinpoint pupils, and a syringe nearby. The EMT should FIRST:
A
B
C
D
Test Your Knowledge
The intranasal dose of naloxone (Narcan) for a suspected opioid overdose is:
A
B
C
D
Test Your Knowledge
Why is pulse oximetry unreliable in carbon monoxide poisoning?
A
B
C
D
Test Your Knowledge
A farmer is found in a field with excessive salivation, lacrimation, urination, and pinpoint pupils after spraying pesticides. This presentation is consistent with:
A
B
C
D
Test Your Knowledge
Which finding differentiates heat stroke from heat exhaustion?
A
B
C
D
Test Your Knowledge
When managing a severely hypothermic patient, why should the EMT handle the patient gently?
A
B
C
D
Test Your Knowledge
A near-drowning victim has been pulled from the water and is not breathing. After ensuring scene safety, the EMT should:
A
B
C
D
Test Your Knowledge
An important consideration when administering naloxone to a patient with suspected opioid overdose is that:
A
B
C
D
Test Your KnowledgeMatching
Match each poisoning or overdose type to its classic signs and symptoms:
Match each item on the left with the correct item on the right
1
Opioid overdose
2
Carbon monoxide poisoning
3
Organophosphate poisoning