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CHAPTER 7: EXAMINING THE PATIENT |
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| Objectives After studying this chapter, you should be able to:
If you are more than two hours journey from a hospital and there is no doctor or health centre nearby, your next step, after giving first aid, should be to examine the patient. It is important to examine the patient so that you can decide how to help the patient until he or she gets to hospital and so that you can give a clear account of the patient's condition if you contact a poisons centre or hospital by telephone or radio. This chapter describes how someone without medical training can examine a patient for the effects of poisoning. Reading it can help you learn what to do and what to look for, but it is best if a trained health care worker shows you how to carry out an examination. Practise counting the pulse and reading a thermometer until you are confident you can do both accurately. Poisons may cause many changes inside the body that can only be measured using medical equipment. Such changes are not discussed here. The effects of poisoning are known as symptoms and signs. Most poisons cause several symptoms and signs because they affect more than one part of the body. For each of the signs described in this chapter there is a box with a list of some of the common chemicals that cause it. To keep the lists short, some of the names are those of groups of chemicals (for example: atropine-like medicines) rather than the names of individual chemicals. The names used here are also used in Part 2, so you can check in Part 2 to see which individual chemicals are included in a group. The lists do not include every chemical that causes a particular effect, so it is possible that a person with one of the signs or symptoms could have been poisoned by a chemical that is not listed. Do not expect a patient
to have all the signs and symptoms listed for a poison. Often it
depends how badly poisoned the patient is. For example, ethanol
(alcohol) can cause unconsciousness, but someone Remember, the patient may have taken more than one poison. What the examination cannot tell you If you have no clue about what the poison might be, the examination is unlikely to give you information that will point to one particular poison, because many poisons cause similar symptoms and signs. However if you already think you know what the poison might be, and what happened, you can check whether you might be right by comparing the patient's symptoms and signs with those listed for specific poisons in Part 2 of this book. You may not be able to tell, just by examining the patient, if the patient is poisoned or if he or she is suffering from another illness or injury, because:
For this reason, when you examine the patient it is important to ask if he or she has now, or used to have, any sickness or disease, and to look for cuts and bruises and other signs of injury. When the patient does not have any symptoms or signs A patient who seems well may not have been poisoned. Remember, exposure to poison will not result in poisoning if a poisonous dose does not get into the body (see Chapter 1). Someone who has been poisoned may seem well because it is too soon for the poison to take effect. Some poisons may not cause any effects for many hours. For example, a person who takes a poisonous dose of paracetamol may be well for up to 48 hours afterwards. So it is important to ask what happened and how long ago. How to examine a patient and find out the symptoms and signs Carry out the examination in the order given in this chapter. As you examine the patient, write down all your findings with a note of the date and time. At regular intervals while you are looking after the patient, check how he or she is and write down any changes in signs and symptoms and the time when you notice them. Give your report to the doctor when you hand over the patient. Talk to the patient If the patient is conscious and can answer questions talk to the patient. Ask what happened Try to find out:
Ask the patient if he or she has had a fall or injury. Ask if the patient knows anybody else in the family, in the village or at work who has had the same sickness. Sometimes the patient can tell you what happened. For example, people usually know if they have been bitten or stung by an animal and they will often tell you when they have taken an overdose of medicine. They may tell you that a chemical product or a pesticide they were using has made them ill. In some circumstances people do not know what happened. For example, people who have been poisoned by carbon monoxide gas may not know what has made them feel sick, because carbon monoxide has no smell and is invisible. People who are sick after using a chemical product or pesticide may not realize that their sickness is due to poisoning. Even when people know what happened they may not be able to tell you much about the poison. People often use chemicals or take medicines without knowing what they contain. Even if they give you the bottle, there may not be any information on the label about the contents. People who have been bitten by a snake may not know what kind of snake it was, and may not be able to give a good enough description for anyone else to identify it. Sometimes people who think they know about wild plants and mushrooms make mistakes in identification. Sometimes people do not know how much poison they have taken. People who take poison because they want to harm themselves may not count how many tablets they take, or measure how much liquid they drink. Some people may not want to tell you the truth and may lie about what they have taken. A child may be too frightened to tell the truth. The patient may be dazed, in shock or confused and not able to answer properly. People who are unconscious cannot tell you anything, and children may be too young to talk or to understand. Later, you may be able to find out more about what happened by asking other people and looking for evidence (see Chapter 8), but examine the patient first. Ask the patient about symptoms Ask if the patient feels pain. Ask where the pain is. Ask whether the patient feels cold, hot, thirsty, weak, sick, dizzy, or faint. Ask how long the patient has felt like this. Ask whether the patient has been unconscious or asleep. A patient who is confused:
Some chemicals that may cause confusion or hallucinations Drugs of abuse: amfetamines, cannabis, cocaine. Pesticides: chlorophenoxyacetate weedkillers, organophosphorus and carbamate pesticides. Other chemicals: camphor, camphorated oil, ethanol, turpentine and other volatile oils. The patient may not be able to hear you. A person poisoned by aspirin or quinine may hear a ringing sound in the ears, or may become deaf. Look for signs of poisoning This section describes how to examine a patient for some common signs of poisoning:
Watch the way the patient behaves Some poisons make the patient restless, overactive, or aggressive. This can also happen when people suddenly stop abusing drugs or drinking alcohol after doing so for a long time. Some chemicals that may cause overactivity, restlessness or irritability Medicines: aminophylline, atropine-like medicines, chlorpromazine and other phenothiazines, ephedrine. Drugs of abuse: amfetamines, cocaine. Strange behaviour may be a sign that the patient abuses drugs or other substances, or it may be a sign of mental illness. The unconscious patient A person who is losing
consciousness may seem very drowsy, may only be able to say yes
or no if you ask questions, or may only be able to obey commands
such as "open your eyes" or "lift up your arm". Unconsciousness is a sign of dangerous illness. Put an unconscious patient in the recovery position so that the tongue does not block the airway. Try to find out whether the patient became unconscious suddenly or gradually became drowsy and fell asleep. Most poisons cause gradual unconsciousness if they have been swallowed. Some chemicals that may cause unconsciousness Medicines: amitriptyline
and other tricyclic antidepressants, antihistamines, atropine-like
medicines, barbiturates, carbamazepine, chloroquine, chlorpromazine
and other phenothiazines, chlorpropamide-like medicines, diazepam
and other benzodiazepines, insulin, iron-containing medicines, meprobamate, Other chemicals: benzene, carbon monoxide, carbon tetrachloride, cyanide, ethanol, ethylene glycol, methanol, toluene, trichloroethane, trichloroethylene, xylene. Many other medicines and chemicals taken in large amounts. Unconsciousness is probably caused by a head injury if the patient also has any of these signs:
Look at the patient Does the patient look ill or weak? Look at the patient's clothes to see if they are damp or stained with chemicals, urine or vomit. Look at the vomit to see whether there is blood, or pieces of tablets, plants, or food in it. Look at the skin Cuts, scratches, bruises, or bleeding may mean the patient is ill because of an injury. Bruises may be caused by a fall. The patient may have been dizzy, unsteady, or very drowsy because of alcohol or drugs. Cuts on the insides of the wrists or on the neck may have been made by the patient trying to kill himself or herself, and scar lines could mean that the patient tried to do this in the past. Marks on the arms near the inside of the elbow, or on the ankles or knees, with swollen veins, ulcers and abscesses may have been caused by injecting drugs. The patient may be dependent on drugs. Burns and stains may
have been caused by corrosive or irritant liquids. Someone who has
been working with a chemical may have burns on the legs, arms, chest,
back, or feet. Someone who has swallowed a Blisters or red patches on the sides of fingers, ankles, knees, shoulders, or other parts of the body show that the patient has been lying unconscious in the same position for several hours. Scaly rashes may be caused by working with irritant chemicals, such as pesticides, or handling irritant plants. Rashes are also caused by some diseases and parasites. A hot pink skin may be caused by some medicines. If the patient has a black or brown skin, feel the skin and look at the hands and inside the lips. A blue colour to the
skin and inside the eyelids and lips means that there is not enough
oxygen in the blood. Usually this means that the patient cannot
breathe properly, but some chemicals make the patient look blue
even though breathing is good. If the patient has a brown or black
skin it may be difficult to see a blue colour to the skin, but the
lips, nails and inside of the lower eyelids will look A yellow skin may be caused by jaundice or by chemicals that stain the skin. Jaundice is caused by liver damage. The liver damage may be due to poisoning or infection, or damage to the blood. The whites of the eyes will also be yellow. It can take up to 48 hours after poisoning before the skin turns yellow. Some yellow or orange substances turn the skin yellow or orange. The medicine called rifampicin gives an orange-red colour to the skin (the stain washes off), urine, stools, tears, and whites of the eyes. Some chemicals that may make the skin change colour Pink, hot skin: atropine-like medicines, amfetamines, and borax. Yellow skin caused by jaundice: carbon tetrachloride, iron containing medicines, paracetamol, pentachlorophenol, trichloroethylene, and some poisonous mushrooms. Yellow or orange stain: dinitrophenol, dinoseb, DNOC, rifampicin (the stain washes off). Blue skin: dapsone, naphthalene, paradichlorobenzene, phenol, sodium chlorate, sodium nitrite. Feel the skin Poisons may cause sweating. Other causes of sweating are infection, shock, heart attack, and low blood sugar in diabetic patients. Some substances cause hot dry skin. A hot dry skin may also be caused by being in a very hot place, or by sickness that causes fever. Look inside the mouth
Smell the breath Many substances make the breath smell, even if only a small amount is swallowed. People may smell of alcohol but not be drunk. People often take alcohol when they take other poisons. If the patient smells of alcohol, look for evidence and signs of other poisons too. Look for evidence of head injury too. Some chemicals that may make breath smell Camphor, camphorated oil, carbon tetrachloride, cyanide, ethanol, methyl salicylate, paraffin, petrol, toluene, trichloroethylene, turpentine and other volatile oils, and many pesticides. Watch and listen to breathing
Count how many times the patient breathes in one minute. If the patient sees what you are doing he or she may breathe faster, so a good plan is to count breathing after taking the pulse, while you are still holding the wrist. Always count for a full minute. Most adults breathe 12-18 times per minute, children and infants breathe 20-30 times per minute. People breathe more quickly when they are taking exercise or when they are excited or upset; they breathe more slowly when they are asleep or resting. In most cases changes in breathing are dangerous and the patient's life may be in danger. Slow and irregular breathing or fast and shallow breathing may be caused by poisoning, substances like vomit or kerosene getting into the lungs, unconsciousness, head injury, stroke, lung oedema (see below), lung infection, asthma, or diabetes. Noisy breathing, with gurgling or snoring noises, may mean that the throat is blocked and not enough air is getting through. The throat may be blocked by food or a foreign body. If the throat is burnt it swells and blocks the airway. In an unconscious patient the throat may be blocked by the tongue, vomit or saliva if the patient is not in the recovery position. Coughing or wheezing may be caused by irritant gases, smoke, or dust. The patient may also have stinging or severe pain in the eyes and nose. Kerosene and similar liquids cause coughing and choking if they are swallowed. Other causes of coughing and wheezing are infections of the lungs, asthma and cigarette smoking. Same chemicals that may change breathing Shallow breathing
Slow or irregular breathing
Fast breathing
Lung oedema Lung oedema is a condition in which fluid fills the lungs and eventually stops the patient breathing. Lung oedema is a very serious condition and the patient's life may be in danger. The signs of lung oedema are:
Some poisons cause lung oedema after a few minutes, others after several hours. As the patient gets tired, breathing may become very slow and may eventually stop. The lungs may fill with fluid in conditions such as heart disease, but it happens in a different way. Some chemicals that may cause lung oedema
Check the pulse The heart is a pump. It pushes blood through the blood vessels. Each time the pump pushes out blood a wave of pressure passes along the blood vessels. This is the heartbeat or pulse. It can be felt wherever the blood vessels are close to the surface of the body, by pressing the blood vessel gently against a bone. Have a watch with a second hand in front of you. To take the pulse at the wrist, press two fingertips of your right hand lightly on the patient's wrist on the same side as the thumb (Fig. 38). You should feel a regular beat; this is the pulse. Count for a full minute looking at your watch. The number of beats you count in one minute is the pulse rate.
Fig. 38. Taking the pulse at the wrist. In children and babies, try to find the pulse on the inside of the upper arm between the elbow and the shoulder. With your thumb on the outside of the child's arm, press your first and middle fingers gently into the groove between the muscles, until you feel a pulse. Sometimes it is easier to feel the heartbeat directly on the left of the chest. A normal pulse is regular and strong. In an adult the pulse rate is between 60 and 80 per minute. In healthy young adults it may be slower (50-60 per minute). In young babies it is faster (120 per minute). The pulse rate is slower than normal during sleep, and faster than normal if the person is excited or moving about, so take the pulse when the person is resting. Note if the pulse is:
If the pulse is very irregular when you feel it at the wrist, count the heartbeat by listening over the heart. You can hear the heartbeat if you put your ear against the nipple on the left side of the chest. The count may be higher this time because you will be able to hear heartbeats that were too weak to be felt at the wrist. Write down what you find. A change in the pulse can mean that the patient is dangerously ill. Poisons may cause a slow pulse or a fast pulse. Any very bad poisoning may affect the heart, so that the pulse becomes irregular or very slow and may even stop altogether. Some chemicals that may cause a slow pulse
A fast, weak pulse can mean shock, bleeding, heart attack, heat exhaustion or fever. A fast, strong pulse can mean heat stroke, stroke, or heart disease. Some chemicals that may cause fast pulse
A slow pulse may be caused by a low body temperature. Measure body temperature It is wise to take a patient's temperature, even if there does not seem to be a fever. If the patient is very sick, take the temperature every 3 or 4 hours. If you do not have a thermometer, feel the temperature by placing the back of one hand on the patient's forehead and your other hand on your own forehead. The forehead of a patient with a fever will feel warmer than yours. If the forehead feels cooler than yours the patient may have a low body temperature. A thermometer can be used to measure temperature in the mouth, armpit, groin or rectum. You should not use the same thermometer in the rectum as you use for taking oral or armpit temperatures. Always use a thermometer with a round end for taking the temperature in the rectum as this will not damage the rectum. To measure temperature:
Some substances that may cause a high body temperature and warm dry skin
Some chemicals that may cause a high body temperature and sweating
A low body temperature may be caused by a long period of unconsciousness, especially if the patient has been lying in an open or cold place. Some chemicals that may cause a low body temperature (less than 35°C)
Look at the eyes Examine both the patient's eyes together. See if the pupils are the same size. Cover one eye at a time with your hand and see if the pupil changes size when the light changes. If you have a light you can shine it into the eyes and see if the pupils get smaller. Unequal pupils-pupils that are not the same size-may be caused by a chemical splashed in one eye. If there has not been chemical in the eye, this is usually a sign of eye disease or brain disease. Large pupils may be a sign of poisoning, or of severe lack of oxygen, or of very low body temperature. Look at the whites of the eyes. If these are yellow this usually means the patient has jaundice. Some chemicals that may affect the eyes Very small "pinpoint" pupils
Large pupils
Blurred vision Loss of sight or complete blindness
Other signs of poisoning Vomiting and diarrhoea may be caused by almost any poison. Other causes of vomiting with diarrhoea are infections caused by bacteria, viruses, or worms, and malaria. Other causes of diarrhoea are allergies to certain foods, side-effects from certain medicines, such as antibiotics or laxatives, or eating too much unripe fruit or heavy, greasy foods. Other causes of vomiting are appendicitis or something blocking the gut, or almost any other sickness with high fever or severe pain, especially migraine headache, and infections of the liver, ears, and brain. Black
stools. The black colour may be caused by blood
from the gut if the gut has been damaged by corrosive fluids. Iron
tablets may colour stools black or dark green, and activated charcoal
also colours Signs of dehydration are as follows: Very severe dehydration may cause a rapid weak pulse, fast deep breathing, fever, or fits. The patient does not pass urine. If a person does not pass urine this could mean any of the following: Some chemicals that may cause kidney failure
The kidneys are making
urine but the bladder is not working; the bladder muscles will not
relax and let the urine out. Do not confuse this reason for not
passing urine with kidney damage. If the bladder is full you should
be able to feel a rounded swelling in the lower part of the belly.
Some medicines stop people
Some medicines that may stop the patient emptying his or her bladder Amitriptyline and other tricyclic antidepressants, antihistamines, atropine-like medicines. Fits (convulsions). These are jerking movements that the patient cannot control. The patient may be just twitching or the whole body may move. The patient may suddenly become unconscious and foam at the mouth. The longer the fit lasts, the greater the danger to life. In severe cases, the patient does not stop having fits and finds it difficult to breathe. There are some kinds of fit where first the jaw and then the whole body becomes very stiff. This may be tetanus. Fits may be caused by poisoning, lack of oxygen - which may be a result of exposure to poison or of something blocking the airway - epilepsy, meningitis, malaria, or low blood sugar in a diabetic person. People dependent on alcohol or drugs may have fits if they suddenly stop taking them. In small children, fits may be caused by high fever or severedehydration. Some chemicals that may cause fits
Some chemicals that may cause liver damage
Poisonous mushrooms Signs that the patient is severely ill
Patterns of symptoms and signs Table 7.1. Poisoning syndromes
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