Transcript Substance Abuse

Substance Abuse
Ray Taylor
Valencia Community College
Department of Emergency Medical Services
Notice
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All rights reserved.
Slide show used with permission only for the
purposes of educating emergency medical
providers (EMTs and Paramedics)
No portion of this presentation may be
reproduced, stored in a retrieval system in any
form or by any means (including but not limited to
electronic, mechanical, photocopying etc.)
without prior written permission from the author
Objectives
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Approach to the overdose patient
Recognize toxic syndromes
Discuss common drugs of abuse
Recognize patterns of substance
abuse
Discuss Alcohol Abuse
Drug Abuse
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Refers to the use of prescription drugs for
nonprescribed medical use
Emergencies resulting from drug abuse
• Adverse effects caused by the drug or impurities
mixed with drugs
• Life threatening infections from IV or intradermal
injection
• Accidents during intoxication
• Drug dependence or withdrawal syndrome
Background
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2.4 to 4 million per
year
Accidental vs. Suicidal
Over half are children
1-5
• Only5% of fatalities
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Conservatively
estimated that 45
million Americans use
drugs in a reactional
way
Adults: chemical
exposure vs. suicidal
Approach to the
Overdose patient
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ABC’s
Coma cocktail
• narcan, D50
• thiamine
Assessment:
history and
physical
Monitoring
Unbiased approach
Approach to the Overdose Patient
Gut Decontamination
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Ipecac
Gastric
Lavage
Activated
Charcoal
Whole Bowel
Irrigation
Dialysis
Ipecac
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Should not be administered routinely
Highly variable
Effectiveness decreases with time
Administration in the ED should be
abandoned
Delays charcoal, antidotes, and
whole bowel irrigation
Why Talk About It Then
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Can mask signs of toxicity
Most useful when unknown or
toxic amount of substance AND
Not close to the ED
Within 60 minutes (solids)
Within 30 minutes (liquids)
Dose:
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6 to 12 months:
• 5 to 10 cc (with
water)
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1 to 12 years:
• 15 cc (with
water)
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12 years and
older:
• 15 to 30 cc
(with water)
Ipecac/Family Guy
Gastric Lavage
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Lavage is
rarely
recommended
Gastric
aspiration
30 minutes
post ingestion
< 40% removed
Activated Charcoal
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Not routinely
administered
Will be used most
often within 1 hour
post ingestion
No data to support or
exclude its use
Recommended dose
of 1g/kg
Don’t need sorbitol
• Makes “shit” come
out faster
Whole Bowel Irrigation
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Should not be administered routinely
Toxic ingestions of SR or EC drugs
Body packers
Stuffers
Start within 4 hours
Polyethylene glycol electrolyte solution
N/G tube needed
Whole Bowel Irrigation
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Adults:
• 1000 cc/hr and increase to 2000cc/hr
Children ( 9 months and up):
• 250 cc/hr and increase to 500 cc/hr
Until rectal effluent is clear
May give AC prior
Do not give MDC during.
MDC after WBI
Toxins
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Toxidromes
• Similar toxins typically have
similar signs and symptoms.
• In some cases it may be difficult
to identify a specific toxin.
Toxic Syndromes
(1 of 5)
Toxic Syndromes
(2 of 5)
Toxic Syndromes
(3 of 5)
Toxic Syndromes
(4 of 5)
Toxic Syndromes
(5 of 5)
Toxic Syndromes
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Anticholinergic
• dry as a bone….
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Sympathomimetic
Opiate/ Sedative
Cholinergic
• SLUDGE
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Serotonin
Drug Abuse
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DSM IV criteria:
• Maladaptive pattern of substance use
leading to impairment manifested by:
• recurrent use resulting to fulfill obligations
• recurrent use in a way that is physically
hazardous
• recurrent legal problems related to usage
• continued use despite persistent social or
interpersonal problems
Substance Abuse
and Overdose
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Addiction
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Habituation
Physiological dependence
Psychological dependence
Tolerance
Withdrawal
Drug Overdose
Common Drugs of Abuse
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Narcotics
CNS
Depressants
CNS Stimulants
Hallucinogens
Drugs of Abuse
Common Drugs of Abuse
(1 of 4)
Common Drugs of Abuse
(2 of 4)
Common Drugs of Abuse
(3 of 4)
Common Drugs of Abuse
(4 of 4)
Narcotics
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Heroin accounts for approximately 90%
of the narcotic abuse in U.S.
Pure heroin is a bitter-tasting white
powder that is usually adulterated (cut)
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Lactose
Sucrose
Backing soda
Starch
Narcotics
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A typical “bag” is the single dose
unit of heroin and may weigh 100mg,
which on average is only 5% pure
Other narcotics include:
• Morphine, methadone, meperidine, codeine,
oxycodone, propoxyphene
• Designer opiates: alpha fentanyl (China White)
Narcotics
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Depending on the narcotic
preparation, these drugs may be
• Taken orally
• Injected intradermally (skin
popping)
• Injected intravenously (mainlining)
• Taken intranasally (snorted)
• Smoked
Narcotic
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CNS depression,
drowsiness, euphoria,
miosis?, slow RR, N,V
W/D symptoms- not life
threatening
Other considerations:
infection, abscess,
NCPE, epidural
abscess, embolization,
Lomotil
Treatment: Naloxone
2mg IV or IM to an 8mg
total
CNS Depressants
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Sedatives/Hypnotic agents
Include benzodiazepines and
barbiturates
Usually taken orally, but may be
diluted and injected intravenously
Use with alcohol increases their
effects
CNS Depressants
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Benzodiazepines are among the
best known and most widely
prescribed drugs to control
anxiety, stress, and insomnia
Work by depressing brain
function and are often abused
for their sedative effects
Benzodiazepines
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Stimulate Gamma-aminobutyric acid
(GABA) receptors
GABA receptors are predominant
inhibitory neuroreceptors in CNS
Stimulation produces sedative
effects
• Alters synaptic transmission in spinal
cord leading to skeletal muscle
relaxation
Benzodiazepines
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Relatively nontoxic, but may
accentuate the effects of other
sedative-hypnotic agents
Common benzodiazepines
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Valium
Librium
Versed
Klonipin
Barbiturates
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General CNS depressants that inhibit
impulse conduction in the ascending
reticular activating system
• Once widely prescribed, but have been
replaced by benzodiazepines
• Commonly prescribed barbiturates
• Phenobarbitol
• Amobarbitol
• Secobarbital
CNS Depressant
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Benzos, Barbituates,
GABA agonists in the CNS
Coma, resp depression, CV
depression
W/D: restlessness, irritable, seizures
BZD are safer
GHB, Rohybnol,
Treatment: Supportive, Flumazenil
CNS Stimulants
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Amphetamines are drugs
frequently used to produce
general mood elevation,
improve task performance,
suppress appetite, and prevent
sleepiness
CNS Stimulants
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Structurally, amphetamines are
similar to endogenous
catecholamines, but differ in their
pronounced effects on the CNS
Adverse effects include:
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Tachycardia
Increased BP
Tachypnea
Agitation
Dilated pupils
Tremors, disorganized behavior
CNS Stimulants
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Severe cases, patients may
exhibit psychosis and paranoia,
and experience hallucinations
Sudden withdrawl of
amphetamine use may result in
“crash” stage
• Patients become depressed,
suicidal, incoherent or comatose
CNS Stimulants
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Amphetamines, cocaine, PCP
Symptoms: euphoria, stimulant,
delirium, SZ, ICH, MI, CVA
The Scope of Cocaine
Cocaine
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One of the most popular illegal drugs
in U.S.
4 million Americans use drug
regularly
Cocaine related deaths are third
leading cause of drug-related
fatalities, proceeded only by heroin
and drug-alcohol combinations
Cocaine
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Most commonly used as a fine white
powder crystalline powder
• Street forms are usually adulterated and
vary in purity from 25%-90%
• Doses vary from near 0 to 200mg
• Usually inhaled intranasally by snorting
a “line” containing 10-35mg of the drug
Cocaine
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After absorption through the
mucus membranes, effects
begin within minutes
Peak effects occur in 15-60
minutes after use
Half life of 1-2.5 hours
Cocaine
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Parenteral administration
• SQ, IV, IM routes
• IV route provides immediate
absorption and intense stimulation
• Peak occurs within 5 minutes and
a half life within 50 minutes
Cocaine
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Feebase or “crack” cocaine
• More potent formulation prepared by
mixing powdered street cocaine with an
alkaline solution and then adding a
solvent such as ether
• Combination separates into 2 layers with top
layer containing the dissolved cocaine
• Evaporation of solvent results in pure cocaine
crystals which are smoked and absorbed via
lungs
Cocaine
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Cocaine in its crystallized form is
called “rock” or “crack”
Popping sound produced when the
crystals are heated
Freebase is often combined with
marijuana or tobacco and smoked in
a water pipe
Equal to IV use in intensity and
pleasure
Cocaine
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Blocks reuptake of NE
Use *benzodiazepine (diazepam 5-20 mg)
Lidocaine (also a sodium channel blocker
like cocaine) – competes with cocaine at
the sodium channel; risk of seizure due to
synergistic toxic effect of Lidocaine in
presence of cocaine
Bicarb early if coded
Cocaine
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Major CNS stimulation that
causes profound sympathetic
discharge
Increased circulating levels of
catecholamines result in
excitement, euphoria,
talkitiveness, and agitation
Cocaine
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Effects of cocaine can precipitate
cardiovascular and neurological
complications
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Cardiac dysrhythmias
MI
Seizures
Strokes (intracranial hemorrhage)
Hyperthermia
Psychiatric disorders
Cocaine
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Can occur with any form of the
drug and route of administration
Adult fatal dose is thought to be
about 1200mg
Fatalities from cocaine induced
cardiac dysrhythmias have been
reported with a single dose of
25-30mg
Cocaine
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Treatment
• Airway and ventilation
• Oxygen administration and monitor saturation
• Cardiac monitoring
• Treat dysrhythmias
• Beta blockade
• IV NS
• Control and treat seizures
• Sympathomimetic toxidrome
(hypertension, tachycardia, agitation)
Valium/Versed
Phencyclidine Overdose
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A dissociative analgesic with
sympathomimetic and CNS
stimulant and depressant
properties
PCP illegally sold in tablet or
powder form to be taken orally,
intranasally or with other drugs
to be smoked
PCP
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Most tablets contain about 5mg
PCP
As a rule, PCP in powder from is
relatively pure (50-100%)
Chronic use results in
permanent memory impairment
and loss of higher brain
functions
PCP
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Low dose toxicity (less than
10mg)
• Produces an unpredictable state of
drunkeness, euphoria, confusion,
disorientation, agitation, or sudden
rage
• Intoxicated patient often has blank
stare, stumbling gait, and is
dissociative
PCP
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Low dose toxicity is best managed
by keeping sinsory stimulation to a
minimum
Violent and combative patients
require protection from self-injury
Closely monitor vital signs
Increasing motor activity and muscle
rigidity of often precedes seizures
PCP
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High dose toxicity (More than
10mg)
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Respiratory depression
Hypertensive crisis
Tachycardia
Coma
PCP psychosis
Treatment
ECSTASY
Methamphetamine Lab
Names
XTC
E
X
LOVER’S SPEED
CLARITY
ADAM
What is Ecstasy?
3,4-Methylenedioxymethamphetamine
“MDMA”
What does it look like?
MDMA ????
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PMA or PMMA
Amphetamine
LSD
2-CB
Aspirin
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Ketamine
Atropine
4-MTA
DXM
Caffeine
How does it work?
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Responds by
releasing
Serotonin,
Dopamine and
Norepinephrine.
How much does one
take?
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Standard oral dose is 80 – 150 mg
• Most good quality pills contain generally
80-120mg
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Once the “sweet spot” is obtained, a
higher dosage is not necessarily
more desirable
Lethal dose 106mg/kg or 6000 mg
Onset and Duration
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Onset 30 – 60
minutes
• Coming up 5-20min.
• Plateau 2-3 hours
• Coming down 1-2
hours
• Duration 3-4 hours
• After affects 3-24
hours
Positive Effects
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Extreme mood lift
Increased
willingness to
communicate
Increased energy
Ego softening
Feeling of love,
comfort & empathy
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Increased
appreciation of
music
Profound lifechanging spiritual
experience
Urge to hug & kiss
Neurotically based
fear dissolution
Neutral Effects
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Visual distortion
Pupil dilation
Appetite loss
Nystagmus
Restlessness, nervousness
Change in body temp regulation
Negative Effects
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Increased HR & B/P
Hyperthermia
Dehydration
Hyponatremia
Nausea & vomiting
Headache,
dizziness
Jaw clenching,
tongue & cheek
chewing
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Post-trip CRASH
Depression
Hangover
Inappropriate &/or
unintended
emotional bonding
Say inappropriate
things
Muscle tension
Long-Term Effects
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Psychological difficulties
- ? permanent brain damage
- confusion
- memory loss
- depression
- sleep disorders
- drug craving
- severe anxiety
- paranoia
Treatment and Care

Treatment is related to
symptoms
- Tachycardia
- Hypertension
- Hyperthermia
- Dehydration
- Hyponatremia
Hallucinogen
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15 million Americans
PCP: nystagmus, agitation-sz coma
LSD: paranoia, anxiety-flashbacks
Peyote (Mescaline): N/V, diaphoresis,
anxiety
Causes sensory experiences outside
the mind
Marijuana: Euphoria, relaxation
Mushrooms: N/V
Hallucinogens
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Substances that cause
perceptual distortions
Most common hallucinogens are
PCP and lysergic acid
diethylamide (LSD)
GHB
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Gamma-Hydroxybutyrate
Grievous Bodily Harm; Georgia Home Boy;
Liquid Ecstasy; Liquid X; Liquid E; Liquid G;
G-Riffick; Organic Quaalude; Somatomax;
Scoop; Easy Lay; Fire Water and Blue Nitro,
Invigorate or Longevity
Naturally occurring component of
metabolism, highest levels found in basal
ganglia & hypothalamus, but also in major
organs
GHB
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Synthesized in 1960s – thought to be
beneficial
Crosses blood-brain barrier turning into
GABA
Stimulates Growth Hormone release aiding in
fat reduction & body building
Now popular among recreational users &
violent criminals
“Date Rape” drug & deadly when mixed with
ETOH
GHB
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GHB ingested, 20-30 mins to brain and binds
with GABA-B receptors inhibiting
noradrenaline release in hypothalamus &
mediating release of an opiate-like substance
in the striatum
GHB also produces a biphasic dopamine
response, increasing the release of
dopamine at high GHB concentrations &
inhibiting its release at lower doses
GHB
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CNS depression (10 mg/kg = short-term
amnesia & hypotonia; 20-30 mg/kg =
drowsiness & sleep; 50-70 mg/kg = hypnosis,
then continue to deep coma) and seizure
activity
Narcan, Charcoal, Atropine for bradycardia,
Physostigmine for coma
Tricyclic
Antidepressants

TCAs are commonly prescribed
in the treatment of depression
• Drugs work by blocking the uptake
of norepinephrine, serotonin, or
both into the presynaptic neuron
• Alters sensitivity of brain tissue to
actions of these chemicals
• Tetracyclic Antidepressants
TCAs
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TCA toxicity is thought to result
from central and peripheral
atropine like anticholinergic
effects and direct effects on
myocardial functions
Commonly prescribed TCAs
• Amitriptyline – elavil, endep,
etrafon, vanatrip, levatate
TCAs

Commonly prescribed TCAs
•
•
•
•
Clomipramine – anafranil
Doxepin – sinequan, zonalon, triadapin
Imipramine – trofinal, impril
Nortriptyline – aventyl, pamelor,
norventyl
• Desipramine - norpramin
• Protriptyline – vivactil
• Trimipramine - surmontil
TCAs
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Symptoms of overdose
• Early
• Dry mouth, blurred vision,
confusion, inability to
concentrate, and occasionally
visual hallucinations
TCAs
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Severe symptoms
• Hypotension
• Anticholinergic effects
• Tachycardia, altered mental status
• Miadriasis
• AV conduction blocks
• Prolonged QT interval
• Wide QRS, VT, VF
• Seizures
• Coma
• Death
TCAs
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Treatment
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Airway and ventilation support
Oximetric monitoring
Cardiac monitoring/BP
Alkalinization (Sodium
Bicarbonate), anticonvulsants,
physotigimine when appropriate
• Magnesium for torsades
Salicylates

Widely available in prescription
and over-the-counter
• Acetylasalicylic acid (aspirin)
• Cold preparations (oil of
wintergreen) methyl salicylates
• Combination with other analgesics
• Oxycodone, propoxphene
Salicylates

Mechanism
• Complex and includes interference
with cellular glucose uptake and
inhibition of enzymes that effect
energy production, amino acid
metabolism and acid buffering in
the body.
• Complications result from chronic
and acute ingestions
Salicylates
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CNS stimulation
• Salicylates initially produce direct
stimulation of the respiratory center
causing and increase in rate and depth
• This early respiratory alkalosis is
followed by a compensatory elimination
of bicarbonate ions by the kidneys and
subsequent compensatory metabloic
acidosis
Salicylates

CNS stimulation
• After this period, there is an
accumulation of intermediate
acids involved in energy
metabolism resulting in profound
metabolic acidosis
Salicylates
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
GI irritation
Glucose metabolism
• Interference with cellular glucose
uptake causes accumulation of
serum glucose followed by its loss


Fluid and electrolyte imbalance
Neurological dysfunction
Salicylates

Coagulation effects
• Alter normal platelet fuction

Treatment
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•
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ABCs, oxygen
Cardiac monitoring
IV NS – large amounts
Activated charcoal
Possible IV glucose and sodium
bicarbonate
Acetaminophen

Commonly prescribed analgesic
and antipyretic agent available
in both prescription and
nonprescription preparations
• Due to its widespread availability,
there is a high incidence of
accidental and intentional
poisionings
Acetaminophen

Hepatic toxicity
• Formation of hepatotoxic
intermediate if not managed within
16-24 hours post ingestion
• 30 standard size (325mg) tablets
are toxic in the average adult
• Causes hepatic necrosis
Acetaminophen

Toxic effects of acute ingestion
• Doses of (140mg/kg or greater) can
be classified in 4 stages
• Mild symptoms – often masked
by other ingested agents
• Moderate – Nausea, vomiting,
abdominal pain, weakness,
fatigue, elevated liver enzymes
Acetaminophen

Toxic effects of acute ingestion
• Severe – Liver function
disruption
• Critical – Liver failure
• Antidotal therapy begun with 1624 hours complete recovery
should occur
Acetaminophen

Emergency care
• Respiratory, cardiac, and
hemodynamic support
• Ingestion <4 hours gastric
decontamination
• Definitive care
• In-hospital administration of Nacetylcysteine (Mucomyst)
Iron
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Forms of Iron
Stages of toxicity
Decontamination
Treatment
Iron Overdose

Approximately 10% of ingested
iron (mainly ferrous sulfate) is
absorbed each day by the small
intestines
• After absorption, iron is converted
and stored in iron storage protein
and transported to liver, spleen,
and bone marrow for incorporation
into hemoglobin
Iron Overdose
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
Ingested iron exceeds the body’s
ability to store it, the free iron
circulates in blood and is deposited
into other tissues
Over ingestion of iron is corrosive to
GI tract mucosa and may produce
bloody vomitus, diarrhea, and dark
stools
Prehospital Treatment: Supportive
Organophosphates
Organophosphates


Organophospates are very common
and can be absorbed readily thru
dermis
Cause over stimulation and disrupts
transmissions in the central and
peripheral nervous systems
• acetylcholine (neurotransmitter
substance)
• acetylcholinesterase (enzyme)
blocked hyperactivity ensues
SLUDGE
• Salivation
• Lacrimation
• Urination
• Defecation
• GI cramping
• Emesis
• Miosis (pinpoint pupils) and
muscle fasciculation
Treatment
• Protect yourself
• Surface Decontamination
• ABC’s
• Aggressive airway management,
suctioning and PPV
• Warn the ED, complete
decontamination
Treatment
• Drug Administration
•Atropine (2mg every 5-15
min. in adults and .05 mg/kg
in Peds)
•Dries secretions,
increases HR
•Diazepam/Lorazepam if
seizures are present
Monitoring
• ECG monitoring (may see all
types of dysrhythmias)
• GI decontamination followed by
activated charcoal if ingested
• Transport immediately
• Surface decontamination is
essential early in the evaluation
and management (Warn the
hospital)
Alcoholism
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Major US problem
High comorbidity
Metabolism
Medical consequences
Alcoholic Emergencies
Disulfiram reaction
ETOH
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Most common substance of abuse in
US
Over 10 million in US; 200,000 die
annually
Involved in 1/2 of MVC fatalities,
most homicides and 1/3 suicides
1/5 total national expenditure for
hospital care
Alcoholism

Causes – 3 factors interact
• Personality
• Environment
• Addictive nature of drug


Also thought genetic and hormonal
factors play a significant part
Anyone can become dependent with
ETOH consumption for long periods
Alcohol Metabolism

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
80-90% metabolized in 30 minutes
Constant rate 20 mg/dL per hour
Rate may increase in chronic
alcoholic
3-5% excreted unchanged through
lungs and kidneys
Remainder metabolized in liver to
CO2 and H2O
ETOH
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CNS depressant
Peripheral vasodilator
Suppresses ADH secretion
Low doses have excitatory and
stimulatory effect
High doses to acute intoxication;
respiratory arrest; hypotension;
hypothermia
Chronic Alcohol Abuse
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Drinks early in day/alone/secretly
Periodic binges/blackouts
GI problems/ “green tongue”
syndrome
Cigarette burns on clothing, linens
Chronically flushed face/palms
Alcohol Abuse

Consequences of Chronic
Alcohol Ingestion
• Poor nutrition
• Alcohol hepatitis
• Liver cirrhosis,
pancreatitis
• Sensory loss in
hands/feet
• Loss of balance and
coordination
• Upper GI hemorrhage
• Hypoglycemia
• Falls (fractures and
subdural hematoma)
ETOH Withdrawal Syndrome




1st – 24-36 hrs – “rum fits”; seizures
2nd – 3rd day (*48-72 hrs after
deprivation) Delerium Tremens
DTs – decreased LOC with
hallucinations
Rx: ABC; chemstrip/BGL; IV; D50
and Thiamine 100 mg if
hypoglycemic/Ativan for seizures

The END