toxicity (such as acetaminophen), most ingested poisons produce signs and symptoms in less than 4 hours, and most efforts to decontaminate the gut (remove an ingested poison) have little value more than 1 hour after ingestion. In acute poisonings, prompt treatment is indicated. After the patient has been evaluated and stabilized, general poison management can be initiated. There are six steps in the initial evaluation and follow-on poison management: 1. Stabilization, which consists of a brief evaluation and assessment directed toward identifying the measures required to maintain life and prevent further deterioration of the patient.  Observe the ABC + D & E (Drug-induced central nervous system (CNS) depression, and undressing/uncovering to Expose the patient for disabilities (injuries) to ensure areas of contact or exposure to a chemical can be seen.)  Check the pupils for size and reactivity to light, and do a basic neurologic exam.  Administer oxygen as needed, IV line for fluids.  Watch for signs and symptoms of anaphylaxis. 2. Evaluation, which must be performed once the patient is stabilized.  Include a full history, physical exam, and ordering of appropriate tests (i.e., labs, EKG, x-rays) directed toward identification of toxic agent, evaluating the severity of toxic effects, and searching for trauma and complications.  Periodically reassess the patient. Look for changes. Monitor vital signs, urine output, and cardiac rhythm.  Record your findings (including time), and respond to important changes appropriately. 3. Prevention or limitation of absorption, through skin decontamination, flushing of eyes, ventilation, stomach emptying, administration of charcoal and cathartics, and whole bowel irrigation. 4. Elimination enhancement, through serially administered activated charcoal, ion-trapping (pH adjustment of the urine to promote excretion of certain poisons), hemodialysis, and hemoperfusion (similar to hemodialysis, but used for larger size molecules). 5. Administration of specific antidotes. Less than 5 percent of poisons have specific antidotes. All patients who present should receive glucose, thiamine, and naloxone. Consider supplemental oxygen. 6. Continuing care and disposition, including a period of observation and education (i.e., poison prevention) or psychiatric counseling. Establish follow-up. THE DIAGNOSIS OF POISONING In most situations, the treatment of a poisoning victim will be under the direction of a medical officer. However, in isolated situations, a Hospital Corpsman must be ready to treat the victim. Poisoning should be suspected in all cases of sudden, severe, and unexpected illness. You should investigate such situations by ascertaining, as quickly and thoroughly as possible, the answers to the following questions:  What are the signs and symptoms of the illness?  What was happening before the illness occurred? (Remember, there may have been a chronic exposure over time with the signs and symptoms just becoming apparent.)  What substances were in use? Could more than one substance have been involved?  Is there a container of the suspected substance? If so, how much was there initially, and how much is there now? (If possible, bring the container to the treatment facility. The label will often identify the contents and the recommended precautions and treatment. The label may also list a contact number for emergency advice. Remember, though, that other people— including you—may become contaminated through contact with the container. Handle it carefully.)  What was the duration of exposure? When did it happen?  What is the location of the bite or injury (if applicable)?  Has this happened before? 5-2