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seventh edition International Trauma Life Support for Emergency Care Providers Patients Under the Influence of Alcohol or Drugs CHAPTER 20 Patients Under the Influence Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Overview • Signs and symptoms of under influence of alcohol and/or drugs • Five strategies to ensure cooperation • Situations to restrain patients and how to handle an uncooperative patient • Special considerations for assessment and management with substance abuse International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Under Influence • Trauma and alcohol or drugs – Car crashes involving alcohol – Substance abusers at greater risk of injury – High rate of alcohol and drug use in fatalities • Suspicion of alcohol or drug influence – Use high index of suspicion, physical exam, history, bystanders, evidence at scene to identify International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Patients Under Influence • Unique challenges for management – Under the influence vs. an emergency – May need to alter management techniques – Many initially refuse treatment – Interaction and cooperation • Consult local protocol, medical direction, and law enforcement for assistance International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Assessment • ITLS Primary and Secondary Surveys • Note: – Mental status – Respiration – Speech – Pupils – Needle marks © Pearson International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Mental Status • Altered mental status – Euphoria – Psychosis – Paranoia – Confusion – Disorientation – Due to head injury, shock, hypoglycemia until proven otherwise Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Under Influence • Respirations – Significantly depressed Opiates and sedatives • Speech – Slurred Alcohol or sedatives – Ramble – Hallucinogens Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Pupils • Constricted – Opiates – Early barbiturate use • Fixed and dilated – High-dose barbiturates • Dilated – – – – Amphetamines Cocaine Hallucinogens Marijuana Courtesy of Louis B. Mallory, MBA, REMT-P International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Commonly Abused Drugs International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Interaction • Interaction style influences cooperation – Offensive and judgmental Can cause patients to be uncooperative Can lengthen on-scene time – Positive and nonjudgmental Can cause patients to be cooperative Easier assessment with all appropriate interventions International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Interaction Strategies • Improving cooperation – Identify yourself and orient patient to surroundings – Treat with respect and avoid being judgmental – Acknowledge concerns and feelings – Let patients know what will be required of them – Ask closed-ended questions for history International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Uncooperative Patient • Interacting with uncooperative patients: – Be firm – Set limits to behavior – Consider physical restraint Only if unable to provide adequate care Show of force may be enough International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Restraints • Know local protocols – Law enforcement – Threat to self – Types of restraints Spinal immobilization Reeves sleeve Soft restraints Chemical International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians © Pearson Patients Under Influence • ITLS Primary and Secondary Surveys • Note: – High risk for infection – Look for clues to substance abuse – Finger-stick glucose for altered mental status – Cardiac monitoring for altered mental status – High-flow oxygen and capnography – Hypothermia and hypotension common International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Specific Treatments International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians NIDA 2009 USA Study • Teenage drug use decreasing • Belief MDMA (ecstasy) not harmful • Concerned with nonmedical use of: – Hydrocodone (Vicodin) – Oxycodone (OxyContin) International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians Summary • Know signs and symptoms of abuse: – Recognize patient who may be impaired – Attention to specific areas for critical changes – Provide lifesaving interventions for substances • Interaction strategies for improving patient cooperation are very important • Safety is primary concern International Trauma Life Support for Emergency Care Providers, Seventh Edition John Campbell • Alabama College of Emergency Physicians