CONTENTS

CONTENTS.............................................................................................................. 0
OPIOID INTOXICATION HISTORY.............................................................................. 1
ORGANOPHOSPHATE INTOXICATION HISTORY..........................................................2
BENZODIAZEPINE INTOXICATION HISTORY..............................................................4
METHANOL INTOXICATION HISTORY........................................................................5
ETHANOL INTOXICATION HISTORY..........................................................................7
STANDARD OPERATING PROCEDURE (SOP) FOR PLACEMENT URINARY CATHERTERS. 9
HEART SOUNDS..................................................................................................... 11
LUNG SOUNDS...................................................................................................... 12
1.

Bronchial Sounds......................................................................................... 12

2.

Bronchovesicular Sounds...............................................................................12

3.

Vesicular Sounds.......................................................................................... 12

4.

Crackles.................................................................................................... 12

5.

Wheezes.................................................................................................... 13

6.

Stridor....................................................................................................... 13

7.

Stertor....................................................................................................... 13

OPIOID INTOXICATION HISTORY

Pertinent history may be obtained from bystanders, family, friends, or emergency medical
services (EMS) providers. Pill bottles, drug paraphernalia, or eyewitness accounts may assist
in the diagnosis.
Occasionally, a trial of naloxone administered by EMS is helpful to establish the diagnosis in
the prehospital setting.
Ingestion time, quantity, and co-ingestants are important aspects of the history and should be
ascertained.

ORGANOPHOSPHATE INTOXICATION HISTORY

Signs and symptoms of organophosphate poisoning can be divided into three broad
categories:
(1) muscarinic effects
Mnemonic devices used to remember the muscarinic effects of organophosphates are
SLUDGE (salivation, lacrimation, urination, diarrhea, GI upset, emesis) and
DUMBELS (diaphoresis and diarrhea; urination; miosis; bradycardia, bronchospasm,
bronchorrhea; emesis; excess lacrimation; and salivation). Muscarinic effects by
organ system include the following:

a. Cardiovascular - Bradycardia, hypotension

b. Respiratory - Rhinorrhea, bronchorrhea, bronchospasm, cough, severe
respiratory distress
c. Gastrointestinal - Hypersalivation, nausea and vomiting, abdominal pain,
diarrhea, fecal incontinence
d. Genitourinary Incontinence
e. Ocular - Blurred vision, miosis
f. Glands - Increased lacrimation, diaphoresis
(2) nicotinic effects
Nicotinic signs and symptoms include
a. Muscle fasciculations
b. Cramping
c. Weakness
d. Diaphragmatic failure
Autonomic nicotinic effects include
a. Hypertension
b. Tachycardia
c. Mydriasis
d. Pallor
(3) central nervous system (CNS) effects
a. Anxiety
b. Emotional lability
c. Restlessness
d. Confusion
e. Ataxia
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f. Tremors
g. Seizures
h. Coma

BENZODIAZEPINE INTOXICATION HISTORY

The history should include the time, dose, any co-ingestants, and whether the overdose was
accidental or intentional. It is also important to determine the duration of benzodiazepine
(BZD) use.
Symptoms of BZD overdose may include the following:
(1)
(2)
(3)
(4)
(5)
(6)
(7)

Dizziness
Confusion
Drowsiness
Blurred vision
Unresponsiveness
Anxiety
Agitation

METHANOL INTOXICATION HISTORY

A careful history should be taken in high-risk patients who report typical symptoms of
methanol poisoning.

Time course
Initial symptoms generally occur 12-24 hours after ingestion. The interval between ingestion
and the appearance of symptoms correlates to the volume of methanol ingested and the
amount of ethanol concomitantly ingested; competitive inhibition exists between the 2
compounds.

Methanol blood levels peak at 30-90 minutes following ingestion and often do not correlate
to the time to symptom appearance.

Neurologic manifestations
Initially, the symptoms of methanol intoxication are similar to those of ethanol intoxication,
often with disinhibition and ataxia. Following a latent period, patients may develop headache,
nausea, vomiting, or epigastric pain. In later stages, drowsiness may rapidly progress to
obtundation and coma.

Seizures may occur, generally as a complication of the metabolic derangement or as a result

of damage to the brain parenchyma.

Cases of axonal polyneuropathy in association with chronic exposure have been reported.
Further, motor neuron disease resembling amyotrophic lateral sclerosis has been documented
in a case report. It is likely that neuropathies and spinal cord dysfunction are underestimated.
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Vision loss
Blindness from methanol inhalation was described as early as 1910. Formic acid accumulates
within the optic nerve, which results in the classic visual symptoms of flashes of light and
blurring.

Patients initially may present with diminished visual acuity, which can progress to scotomata
and scintillations. The frank blindness that develops sometimes responds to immediate
therapy; however, complete loss of vision is a common sequela.

ETHANOL INTOXICATION HISTORY

Ethanol intoxication is often difficult to diagnose in young children and toddlers. Important
questions to ask parents include the following:
(1) Was a source of ethanol easily available to the child? For instance, was an open
alcoholic drink left out after a party?
(2) Is the alcohol in the house locked up? Are ethanol beverages in a place that the child
can easily reach?
(3) Is the child taking any over-the-counter medications that might contain alcohol, such
as cough and cold medications?
(4) Could older siblings in the house have given the child alcohol?
(5) Did the parents give the child an alcohol bath?
(6) Did the child drink an ethanol-containing substance (eg, perfume, cleaning fluids) not
meant to be ingested?
If ingestion is known or suspected, determining exactly what and how much the patient
ingested is important. The name, composition, and concentration of the alcohol are helpful.
(1) If the amount is unknown, have the parents estimate how much was in the container
and subtract that amount from the total volume of the container to estimate the
amount ingested or possibly ingested.
(2) The amount of ethanol in a product is often expressed as a percentage, which is the
ratio of the volume of pure ethanol to the total volume of fluid.
a. The formula for determining the percentage of ethanol is as follows: X% = X
g/100 mL
b. The concentration of ethanol in distilled spirits may be expressed as a proof,
which is equal to twice the percentage of ethanol.
(3) Ethanol concentrations in some common substances are as follows: liquid cold
remedies, 2-25%; mouthwashes, 7-27%; rubbing alcohol, usually 70% (although most
commonly, rubbing alcohol contains isopropanol); aftershave lotions, 15-80%; and
perfumes and colognes, 25-95%. Other toxic alcohols are also often found in these
products, such as methanol in perfume or cologne.
(4) Ethanol concentrations in some common alcoholic beverages are as follows: whiskey,
40-60%; liqueurs, 22-50%; wine, 8-16%; and beer, 3-7%.

Be aware that patients often grossly underestimate the amount of Ethanol that they ingested.
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Obtain a history from the emergency medical services (EMS) personnel, parents, relatives, or
anyone else who accompanied the patient to the hospital.
Because ethanol predisposes patients to other causes of altered mental status (eg, trauma),
consider the other causes as well.

Be aware of the other substances in the ingested fluid that may be toxins.
Because of potential legal implications in the United States, pediatric patients are often
evasive in stating their history of possible ingestion. Outside the United States, ethanol
consumption by children is often more culturally acceptable and less stigmatized.

Adolescents often present to the emergency department (ED) with acute illness or decreased
mental status. Often, these patients do not admit to their use of alcohol. Assess for a history of
possible ethanol use in all patients who present to the ED with an altered mental status.

A positive family history of alcohol abuse is significant because children of parents with
alcoholism have a 2-fold to 4-fold increased risk of alcoholism.

STANDARD OPERATING PROCEDURE (SOP) FOR

PLACEMENT URINARY CATHERTERS
1. Explain the procedure and the rationale for the catheterisation to the patient/ parent/
guardian.
2. Wash hands with liquid soap and water then alcohol gel.
3. Put on a plastic apron.
4. Prepare a trolley or appropriate surface area with the required equipment and take it to
the patients bedside.
5. Explain the procedure and ensure privacy.
6. Prepare the patient. Ensure the patient is not unduly exposed.
7. Place protective sheeting below the patients buttocks.
8. Decontaminate hands with alcohol hand rub.
9. Open the packs.
10. Decontaminate hands with alcohol hand rub.
11. Don sterile gloves (both pairs).
Female Patients: Thoroughly cleanse the vulval area with either sterile saline/
sterile water or tap water swabbing from above downwards. Cleanse the labia

minora vestibule in turn. Identify the urethral meatus and cleanse.

Male Patients: Cleanse the glans penis with either sterile saline/sterile water or
tap water. In non-circumcised patients, retract the prepuce (foreskin) slightly
to enable the glans penis to be cleansed and the urethral opening to be visible.
NB Do not fully retract a phimotic foreskin. Remember to return the foreskin

to its normal position once the procedure is completed.

Male and Female Patients:
a. Arrange sterile drape beneath the patient.
b. Inform the patient that the local anaesthetic is cold and may sting.
c. Apply sterile single-use anaesthetic gel. If using anaesthetic gel
anaesthetize urethra by applying for adults, 6mls female or 11mls male of
d.
e.
f.
g.
h.
i.
j.
k.

local anaesthetic slowly and evenly into the urethra.

Allow a minimum of 5 minutes to elapse before passing the catheter.
Discard first pair of gloves.
Position sterile bowl to catch urine.
Open inner cover of the catheter.
Lubricate the tip of the catheter using a swab covered in anaesthetic gel.
Gently insert the catheter and monitor flow of urine.
(Female patients: Do not touch any part of the vulva with the catheter).
(Male patients: ensure that the glans penis is held at an angle away from
the abdomen during catheterisation to allow the smooth passage of the
catheter).
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l. Steady catheter in place and insert up to 10mls of sterile water into the
m.
n.
o.
p.

catheter balloon as per manufacturers instructions.

Attach to a closed drainage system or catheter valve.
Check the patient is comfortable, free from pain and dry.
Clear away any equipment, remove gloves and decontaminate hands.
Ensure that the connection between the catheter and the urinary drainage
system is not broken except for sound clinical reasons, e.g. change the bag

as per manufacturers recommendation.

q. Ensure correct positioning of catheter drainage system as
permanufacturers instructions (on a stand for acute patients).
r. Make the patient comfortable.
s. For hospitalised patients educate the patient on the importance of fluid
intake and good hygiene.
t. Decontaminate hands.
u. Report any abnormalities to medical staff.
v. Record in nursing documentation; the insertion date, balloon volume and
reason for catheterisation, lubricant used, batch number and type of
catheter used.

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HEART SOUNDS

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LUNG SOUNDS

1. Bronchial Sounds
Bronchial breath sounds consist of a full inspiratory and expiratory phase with the inspiratory
phase usually being louder. They are normally heard over the trachea and larynx. Bronchial
sounds are not normally heard over the thorax in resting animals. They may be heard over
the hilar region in normal animals that are breathing hard (i.e. after exercise). Otherwise,
bronchial sounds heard over the thorax suggest lung consolidation and pulmonary disease.
Pulmonary consolidation results in improved transmission of breath sounds originating in the
trachea and primary bronchi that are then heard at increased intensity over the thorax.
2. Bronchovesicular Sounds
Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened and softer
expiratory phase. They are normally heard over the hilar region in most resting animals and
should be quieter than the tracheal breath sounds. However, in sheep, goats, llamas, and
alpacas, they may be heard throughout the full lung field and are often louder than tracheal
breath sounds. Increased intensity of bronchovesicular sounds is most often associated with
increased ventilation or pulmonary consolidation.
3. Vesicular Sounds
Vesicular breath sounds consist of a quiet, wispy inspiratory phase followed by a short,
almost silent expiratory phase. They are heard over the periphery of the lung field. As stated
earlier, these sounds are NOT produced by air moving through the terminal bronchioles and
alveoli but rather are the result of attenuation of breath sounds produced in the bronchi at the
hilar region of the lungs. These sounds may be absent or silent in the periphery of normal
resting animals. They are highly variable in intensity depending on the species, ventilation,
and body condition. Increased intensity may be associated with pulmonary consolidation.
4. Crackles
Crackles are discontinuous, explosive, "popping" sounds that originate within the airways.
They are heard when an obstructed airway suddenly opens and the pressures on either side of
the obstruction suddenly equilibrates resulting in transient, distinct vibrations in the airway
wall. The dynamic airway obstruction can be caused by either accumulation of secretions
within the airway lumen or by airway collapse caused by pressure from inflammation or
edema in surrounding pulmonary tissue. Crackles can be heard during inspiration when
intrathoracic negative pressure results in opening of the airways or on expiration when
thoracic positive pressure forces collapsed or blocked airways open. Crackles are heard more
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commonly during inspiration than expiration. They are significant as they imply either
accumulation of fluid secretions or exudate within airways or inflammation and edema in the
pulmonary tissue.
5. Wheezes
Wheezes are continuous musical tones that are most commonly heard at end inspiration or
early expiration. They result as a collapsed airway lumen gradually opens during inspiration
or gradually closes during expiration. As the airway lumen becomes smaller, the air flow
velocity increases resulting in harmonic vibration of the airway wall and thus the musical
tonal quality. Wheezes can be classified as either high pitched or low pitched wheezes. It is
often inferred that high pitch wheezes are associated with disease of the small airways and
low pitch wheezes are associated with disease of larger airways. However, this association
has not been confirmed. Wheezes may be monophonic (a single pitch and tonal quality heard
over an isolated area) or polyphonic (multiple pitches and tones heard over a variable area of
the lung). Wheezes are significant as they imply decreased airway lumen diameter either due
to thickening of reactive airway walls or collapse of airways due to pressure from
surrounding pulmonary disease.
6. Stridor
Stridor are intense continuous monophonic wheezes heard loudest over extrathoracic
airways. They tend to be accentuated during inspiration when extrathoracic airways collapse
due to lower internal lumen pressure. They can often be heard without the aid of a
stethoscope. Careful auscultation with a stethoscope can usually identify an area of
maximum intensity that is associated with the airway obstruction. This is typically either at
the larynx or at the thoracic inlet. These extrathoracic sounds are often referred down the
airways and can often be heard over the thorax and are often mistaken as pulmonary
wheezes. Stridor is significant and indicates upper airway obstruction.
7. Stertor
Stertor is a poorly defined and inconsistently used term to describe harsh discontinuous
crackling sounds heard over the larynx or trachea. It is also described as a sonorous snoring
sound heard over extrathoracic airways. Stertor does not have the musical quality of stridor.
Stertor is significant as it is suggestive of accumulation of secretions within extrathoracic
airways.

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