Transcript ER Alcohol Substance Abuse

Alcohol Substance Abuse
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Incidence of Illicit Drug
Emergencies
 There is a high potential for EMS involvement in
illicit drug emergencies
 National Institute on Drug Abuse keeps data
 14.5 million people use illicit drugs regularly
 20 million people have tried cocaine
 860,000 people use cocaine weekly
 11.6 million people use marijuana regularly
 770,000 people use hallucinogens (ie: LSD, PCP)
regularly
 2.5 million people have used heroin
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Illicit Drug Behavior
 Substance abusers are 18 times more likely to
be involved in criminal activity
 Violent crimes and thefts to support drug habits
 Drug overdoses
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Accidental
Miscalculation of dosing
Changes in strength of drug
Suicide attempt
Polydrug use
Recreational drug use
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Definition of Terms
 Substance/drug abuse
 Use of pharmacological substances for purposes other than a medically defined
reason
 Drug dependence/addiction
 A craving for the drug, an overwhelming feeling of the need to obtain and
continue to use the drug
 Tolerance
 The need for increasingly higher amounts of the drug to get the same effects
 Withdrawal
 A psychological or physical reaction when the substance is stopped
 Most signs and symptoms of withdrawal are the exact opposite of what
exposure to the substance causes
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Poison Control Centers
 Set up to assist in treatment of poison victims
 Provides information on new products and new
treatment approaches
 Staffed with trained experts 24/7
 Information updated regularly
 Consultation can assist in determining potential toxicity
to the patient
 Can provide definitive treatment information that should
be started
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Routes of Exposure
 Ingestion
 Can cause immediate or delayed effects
 Inhalation
 Rapid absorption via alveoli in the lungs
 Topical
 Entry across the skin or mucous membranes
 Injection
 Can cause immediate and delayed effects
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Commonly Abused
Depressant Drugs
 Alcohol
 CNS depressant
 Binge drinking equals BAC > 0.08 (80)
 Men – typically 5+ drinks in 2 hours
 Women – typically 4+ drinks in 2 hours
 Alcohol poisoning
 Affects the respiratory center in the brain
 Vomiting leads to aspiration & asphyxiation
 Sobering up
 Need time
 Caffeine does not help – really!
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Alcohol continued
 < 0.08 (80) - legal limit in California
 0.30 (300) – stupor, passed out,
difficult to awaken
 0.35 (350) – typical for coma
 0.40 (400) – coma, possibly death due
to respiratory arrest
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Alcohol continued
 BAC continues to rise even after passing out
 Alcohol in the stomach and intestines continues to enter
the blood stream
 A fatal dose can be ingested before becoming unconscious
 General signs/symptoms
 Mental confusion
 Vomiting
 Seizures – often related to hypoglycemia
 Slow/irregular breathing
 Hypothermia
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Alcohol Withdrawal
 With abrupt cessation of alcohol after prolonged
ingestion, there is an overreaction of the brain and
other mechanisms
 Early symptoms can start 6-8 hours after last drink
 Delirium Tremons can last 2-7 days
 Treatment is benzodiazepines and possibly ICU
admission
 SEIZURE PRECAUTIONS
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Commonly Abused Depressant
Drugs
 Narcotics/opiates
 CNS depression
 Heroin
 Hydromorphine
 Darvon, Darvocet
 Heroin – most abused of the narcotics
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Physical and psychological dependence
Addiction and physical tolerance
Mood swings, severe constipation
Menstrual irregularities
Lung damage, skin infections
Seizures, unconsciousness, coma
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Narcotics
 Typical signs and symptoms
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Pinpoint pupils
No physical pain; rush of pleasurable feelings
Lethargic, drowsy, slurred speech
Shallow breathing
Sweating, vomiting
Hypothermia
Sleepiness
Loss of appetite
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Heroin: Background
 Heroin comes from opium poppy capsules.
 Heroin is usually injected, but it can be sniffed, snorted
or smoked.
 Typical heroin user injects up to 4 times a day.
 Intravenous injection provides greatest intensity and
rapid onset (7-8 seconds).
 IM injection produces a slower response (5-8 minutes).
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Heroin: Background
 White powdery substance
 Heroin enters the brain, where it is converted to
morphine
 Due to needle use, heroin users are at risk for:
 HIV
 Hepatitis-C
 Other bloodborne pathogens
 NEW TREND: mixing heroin & fentanyl
 Increases number of deaths from respiratory depression
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Heroin
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Black Tar Heroin
 Is produced in Mexico
 Color and consistency of tar resulting from
crude processing
 Most frequently dissolved, diluted, and
injected
 It’s unlikely a white powder heroin user will
switch to black tar heroin unless there is a
significant supply interruption
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Black Tar Heroin
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Treatment of Heroin
 Scene Safety
 Due to the increased risk for Bloodborne Pathogens, PPE is
extremely important
 Be cautious of any needles that may be hidden from view.
This is NOT the patient you want an accidental stick from!
 This population has a high incidence of HCV and HIV
 ABC’s
 IV, O2, & monitor
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Treatment of Heroin
 Watch for pulmonary edema
 In some heroin overdoses this can occur
 Respiratory support early!
 Ventilate at a rate of 10 breaths per
minute
 1 breath every 6 seconds
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Treatment of Heroin
 Narcan quickly reverses the effects of heroin on the CNS
(usually within 5 minutes)
 Generally, these patients are not pleased to have their
“high” wiped out by our Narcan
 May cause withdrawal symptoms including seizures
 If large doses of heroin were used, there could be a
relapse when the Narcan wears off
 Narcan may be shorter acting based on dose of heroin
taken
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Heroin…
 http://youtu.be/Hj6NvwDLjAE
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Cocaine: Background
 A central nervous system stimulant
 Two forms
 Powder that can be snorted or dissolved in water and
injected
 Crack that comes in a rock crystal form that can be heated
and the vapors smoked
 Effects occur more rapidly than cocaine
 Effects more intense than cocaine
 Effects do not last as long as cocaine
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Cocaine: Background
 Cocaine is the most potent stimulant of natural origin
 One of the oldest identified drugs
 Coca leaves (source of cocaine) have been ingested for
thousands of years
 Is not used medically today due to high potential for
abuse and addiction
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Cocaine
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Crack Cocaine
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Cocaine: Pathophysiology
 Cocaine related dysrhythmic fatalities occur in patients
with low or moderate levels of cocaine use
 Tachydysrhythmias most common
 Hearts of cocaine users are 10% heavier than noncocaine users
 Increase QRS voltage indicative of ventricular
enlargement
 Conduction delays resulting in widening of the QRS and
prolonged QT segment
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Cocaine: Myocardial Effect
 Regular use of cocaine increases risk of AMI
 Increased heart rate and B/P results in increased
myocardial O2 demand
 Accelerates coronary atherosclerosis process
 May also induce coronary artery spasms
 During withdrawal, may have increased incidence of ST
elevation indicating acute MI
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Cocaine: Signs & Symptoms
 Paranoia
 Dilated pupils
 Dry mouth/nose
 Hyperactivity
 Tachycardia
 Euphoria
 Hypertension
 Irritability
 Disturbance of heart rhythm
 Anxiety
 Chest pain
 Excessive talking
 Heart failure
 Depression or excessive sleeping
 Respiratory failure
 Long periods without eating or sleeping
 Strokes/seizures
 Weight loss
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Cocaine: Agitated Delirium
 Common in patients dying from cocaine
toxicity
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Bizarre and violent behavior
Aggression/combativeness
Hyperactivity/unexpected strength
Hyperthermia
Extreme paranoia
Followed by cardiac arrest!
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Cocaine: Restraints
 Restraints have been implicated as a contributing
factor for user deaths during prone restraint
 Sudden death appears to have been induced by
a combination of three factors that increases
oxygen demand and decreases oxygen delivery
 See next slide
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The three factors:
1. Cocaine induced state of agitated delirium
coupled with police confrontation places stress
on the heart
2. Hyperactivity associated with the delirium
coupled with the struggling against
restraints/police increases oxygen demands
3. The prone position on the cot impairs breathing
by inhibiting chest wall and diaphragmatic
movement and inhalation of fresh oxygen vs
exhaled carbon dioxide
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Cocaine: Treatment
 Make certain the scene is safe
 Not only is there potential for your patient to become
violent, but for bystanders that may be users as well
 Establish ABC’s
 Oxygen
 EKG (12-lead) and monitor continuously
 IV of Normal Saline at TKO unless need for volume is
indicated
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Cocaine: Treatment
 Frequent vital signs with temperature levels
 Monitor temperature often; may continue to rise
 Obtain glucose level
 Use Narcan carefully in patients with altered mental status
 If safe to do so, avoid restraints as this could cause risks
associated with hyperthermia
 Remove any residual cocaine from nares
 Protect your skin from potential absorption
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Cocaine: Cardiac Arrest
Concerns
 Epinephrine
 Hyper-adrenergic state caused by cocaine increases
myocardial oxygen demand.
 Epinephrine has the same effect
 Cocaine frequently causes acidosis
 Epinephrine loses much effectiveness in an acidotic
environment
 Benzodiazepines
 Benzodiazepines (ie: Valium®, Versed®) are used to control
seizure activity
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Benzodiazepines
 Tranquilizers
 Valium®
 Librium®
 Xanax®
 Halcion®
 Ativan®
 Diazepam (Valium®) may be fatal
when mixed with alcohol, opiates,
and other depressants
 Nearly impossible to take a fatal dose of Valium® when not
mixed with any other product, especially alcohol
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Amphetamines
 Stimulant
 Benzedrine
 Dexedrine
 Ritalin
 Used by prescription to treat attention deficit
hyperactivity disorder (ADHD)
 Ephedrine and pseudoephedrine a component in
cold preparation medications
 Used as decongestant
 Used for illicit manufacture of methamphetamine
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Methamphetamine
 To control production of methamphetamine from
over-the-counter products, controls in place
 Sales of products restricted
 Limited quantities purchased for every 30
days
 Must be of a minimum age
 Must show proper identification
 Above controls have contributed to decrease in meth
labs
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Crystal meth: Background
 Dates back to WW II to reduce fatigue and
suppress appetite
 Crystal Meth is typically smoked like crack
cocaine
 Can also be ingested orally or injected
 Easy to make in small clandestine laboratories
 Prior to 1990’s was made using ephedrine
 Pseudoephedrine became new ingredient
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Crystal Meth
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Crystal Meth:
Pathophysiology
 Causes vasoconstriction as well as
bronchodilation
 May last up to 4 and 6 hours after a small
ingested dose
 Effect on the brain is due to norepinephrine and
dopamine
 High doses of amphetamine can cause
palpitations and chest pain with a risk of
myocardial infarction
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Crystal Meth: Signs &
Symptoms
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Dilated pupils
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Weight loss
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Dry mouth
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Increased HR, BP &
Temperature
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Euphoria
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Restlessness
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Decreased appetite
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No interest in food or sleep.
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Rapid speech
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Violent
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Paranoia
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Irritability/Argument
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Depression
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Nasal congestion
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Insomnia
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Crystal Meth: Treatment
 Scene safety
 Extra caution needed if there is suspected meth lab on scene
 Highly explosive potential for years due to chemicals
used and residue left behind in the environment
 Meth lab requires Haz-Mat response
 ABC’s
 IV, O2, & EKG
 Important to monitor EKG continuously due to potential cardiac issues
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Meth Lab Recognition
 UNUSUAL ODORS – Making meth produces powerful
odors that may smell like ammonia or ether. These
odors have been compared to the smell of cat urine or
rotten eggs
 COVERED WINDOWS – Meth makers often blacken or
cover windows to prevent outsiders from seeing in
 STRANGE VENTILATION – Meth makers often employ
unusual ventilation practices to rid themselves of toxic
fumes produced by the meth-making process. They
may open windows on cold days or at other seemingly
inappropriate times, and they may set up fans, furnace
blowers, and other unusual ventilation systems.
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Meth Lab Recognition
 ELABORATE SECURITY – Meth makers often set
up elaborate security measures, including, for
example, "Keep Out" signs, guard dogs, video
cameras, or baby monitors placed outside to
warn of persons approaching the premises.
 DEAD VEGETATION – Meth makers sometimes
dump toxic substances in their yards, leaving
burn pits, "dead spots" in the grass or
vegetation, or other evidence of chemical
dumping.
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Meth Lab Recognition
 EXCESSIVE OR UNUSUAL TRASH – Meth makers produce large
quantities of unusual waste that may contain, for example:
 packaging from cold tablets
 lithium batteries that have been torn apart
 used coffee filters with colored stains or powdery residue
 empty containers – often with puncture holes – of antifreeze,
white gas, ether, starting fluids, Freon, lye, drain opener, paint
thinner, acetone, alcohol, or other chemicals
 plastic soda bottles with holes near the top, often with tubes
coming out of the holes
 plastic or rubber hoses, duct tape, rubber gloves, or
respiratory masks.
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Meth Labs – A Dangerous Place
 Typical products used
 Explosive
environments
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Club/Rave/Party Drugs
 Very popular in universities, nightclubs, and party
environments
 Ecstasy – MDMA
 Modified form of methamphetamines
 Rohypnol – Date rape drug, roofies
 Strong benzodiazepine
 Often used for sexual purposes
 To stimulate and enhance the sexual experience
 To sedate and cause amnesia to facilitate raping the victim
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Ecstasy/MDMA: Background
 Research in animals has shown damage to specific
neurons in the brain
 Has stimulant and hallucinogenic properties
 Reduces inhibitions, eliminates anxiety and produces
feeling of empathy for others
 Enables users to endure all night and sometimes 2-3 day
parties
 Suppresses need to eat, drink, or sleep
 Effects begin in 30 minutes; last 4 – 6 hours
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Ecstasy: Background
 Is taken orally – pill form with multiple logos
 May cause psychological addiction
 Polydrug use often involved
 Mix of a variety of chemicals simultaneously taken
 Product only manufactured illegally
 Can be questionable regarding composition
 There are no specific treatments for MDMA abuse and
addiction
 In high doses can cause severe hyperthermia
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Ecstasy
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Ecstasy: Signs & Symptoms
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Dilated pupils
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Intense euphoria
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Peacefulness
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Empathy/sympathy/acceptances
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Increased B/P, heart rate
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Sweating
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Constant motion, excessive talking
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Teeth clenching (use pacifiers or cigarettes)
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Muscle spasms
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Ecstasy: Treatment
 Normal scene safety precautions
 ABC’s
 IV, O2, and EKG monitor
 Monitor temperature
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Rohypnol®
 Benzodiazepine smuggled into the USA
 Best known as “date rape” drug
 Placed into alcoholic drink of unsuspecting victim
 Removes inhibitions, causes blackouts and
memory loss when mixed with alcohol
 Victim incapacitated; has soothing effect
 Amnesic to the events
 Long-lasting
 10 times more powerful than Valium®
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Synthesized Marijuana
 Labeled “not for human consumption”
 But is regularly smoked
 Produces a marijuana type high at low doses
 Can’t guarantee dosage in the different brands
 Popular to use because not traceable in drug tests
 Can increase heart rate, B/P, seizure activity,
hallucinations, and paranoia
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Supplemental Oxygen
 Delivered to patients when:
 Hypoxemia is evident with oxygen saturation <94%
 Signs of respiratory distress are evident
 Capnography is most accurate method to measure exhaled
carbon dioxide (CO2) levels
 Evaluates effectiveness of ventilations
 Evaluates effectiveness of CPR
 Can determine return of spontaneous circulation (ROSC) during
CPR
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