Developed by:

Phillip Graham

Captain/Paramedic

Red, White and Blue Fire Protection District

1

Objectives

Describe the incidence of illicit drug abuse

emergencies.

Define the terms substance/drug abuse, drug

dependence/addiction, tolerance, and

withdrawal.

Discuss the role of poison control centers.

Discuss the routes of entry of toxic substances

into the body.

2

Objectives Continued

List the commonly abused street drugs and

toxic substances.

Describe signs and symptoms of street

drug and toxic substances used.

Describe withdrawal effects of typical street

drugs.

Describe treatment options for patients

who are under the influence of street drugs

and toxic substances.

3

Objectives Continued

Describe transport issues regarding the

patient who has overdosed.

Review the reconstitution of glucagon.

Review the use of the MAD device.

Review ventilatory rates using the BVM.

4

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

5

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

Accidental

Miscalculation of dosing

Changes in strength of drug

Suicide attempt

Polydrug use

Recreational drug use

6

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

7

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

8

Poison Control Center

240per day/7 days per week

9

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

10

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!

11

Alcohol Continued

< 0.08 (80) - legal limit in Colorado

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

12

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

13

Commonly Abused Depressant Drugs

Narcotics/opiates

CNS depression

○ Heroin

○ Hydromorphine

○ Darvon, Darvocet

Heroin – most abused of the narcotics

○ Physical and psychological dependence

○ Addiction and physical tolerance

○ Mood swings, severe constipation

○ Menstrual irregularities

○ Lung damage, skin infections

○ Seizures, unconsciousness, coma

14

Narcotics

Typical signs and symptoms

Pinpoint pupils

No physical pain; rush of pleasurable feelings

Lethargic, drowsy, slurred speech

Shallow breathing

Sweating, vomiting

Hypothermia

Sleepiness

Loss of appetite

15

16

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).

17

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

18

Heroin

19

Treatment of Heroin

Scene Safety

Due to the increased risk for Bloodborne Pathogens,

BSI 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

20

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

21

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

22

Heroin…

http://youtu.be/Hj6NvwDLjAE

http://youtu.be/6mSq69FT3jM

23

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

24

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

25

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 non-cocaine users

Increase QRS voltage indicative of ventricular enlargement

Conduction delays resulting in widening of the QRS and prolonged QT segment

28

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

29

Cocaine: Signs & Symptoms

Dilated pupils

Hyperactivity

Euphoria

Irritability

Anxiety

Excessive talking

Depression or excessive sleeping

Long periods without eating or sleeping

Weight loss

Paranoia

Dry mouth/nose

Tachycardia

Hypertension

Disturbance of heart rhythm

Chest pain

Heart failure

Respiratory failure

Strokes/seizures

30

Cocaine: Agitated/ Excited Delirium

Common in patients dying from cocaine toxicity

Bizarre and violent behavior

Aggression/combativeness

Hyperactivity/unexpected strength

Hyperthermia

Extreme paranoia

Followed by cardiac arrest!

31

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

32

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

33

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

34

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

35

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

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

36

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

37

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

38

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

39

40

From a print ad from the Partnership for a Drug Free America

Crystal Meth

41

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

42

Crystal Meth: Signs & Symptoms

Dilated pupils

Dry mouth

Euphoria

Decreased appetite

Rapid speech

Irritability/Argument

Depression

Nasal congestion

Insomnia

Weight loss

Increased HR, BP &

Temperature

Restlessness

No interest in food

or sleep.

Violent

Paranoia

43

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

44

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.

45

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.

46

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.

47

Meth Labs – A Dangerous Place

Typical products used

Explosive environments

48

Club/Rave/Party Drugs

Very popular in university’s, 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

49

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

50

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

51

Ecstasy

52

Ecstasy: Signs & Symptoms

Dilated pupils

Intense euphoria

Peacefulness

Empathy/sympathy/acceptances

Increased B/P, heart rate

Sweating

Constant motion, excessive talking

Teeth clenching (use pacifiers or cigarettes)

Muscle spasms

53

Ecstasy: Treatment

Normal scene safety precautions

ABC’s

IV, O2, and EKG monitor

Monitor temperature

54

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®

55

Synthesized Marijuana

An incense spice sold in Illinois

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

56

Treatment of Patients Under the Influence

No specific SOP for “under the influence”

Need to refer to SOP based on assessment and

general impression of patient

SOP’s to consider

Routine Medical or Trauma Care

Altered Mental Status

Tachycardia

Psychological Emergency

Sexual Assault

Seizures

57

Supplemental Oxygen

Delivered to patients when:

Hypoxemia is evident with oxygen saturation <90%

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

58

Transportation of Patients Under the

Influence

Scene Safety – Scene Safety – Scene Safety

Attempt verbal de-escalation Patients fighting mechanical restraints could increase

the adrenalin rush

If patient restrained, document reason why and distal circulation status of the extremities

Monitor airway closely Be prepared for aspiration precautions

○ Suction ready

○ Repositioning of patient

Be prepared to ventilate the patient with depressed respirations

Consider use of Narcan if narcotics suspected

59

Review Equipment

Do you know how to reconstitute Glucagon?

Have you delivered medication via the MAD

device yet?

Do you know the ventilation rate if you have to

support a patient’s ventilations?

60

Glucagon Reconstitution

Glucagon must be reconstituted prior to

administration

Supplied in vials

1 unit of powder generally in compressed form

1 ml of diluting solution

61

Glucagon Administration

Draw up the diluent and add to vial with

powder

Cleanse off vial tops with alcohol wipe

Once the diluent has been added to the

powder, gently roll the vial to mix the contents

Check that all particles have been dissolved

prior to drawing up the medication

Inject glucagon as an IM

Always, always, always aspirate prior to

injecting medications

62

Medication Delivery via MAD

Mucosal atomization device

Tool to deliver medications via nasal route

Medication atomized into tiny particles

Nasal mucosa highly vascular

○ Immediate absorption into bloodstream

○ Maximum volume per nare is 1 ml

○ Use equal divided doses per nares

63

Preparing the Syringe

Variety of ways to prepare the syringe with the

MAD tip

Goal is to deliver a maximum of 1 ml of volume

per nare

Acceptable to use one syringe and deliver half

the dose into one nare, then place the same

MAD tip into the 2nd nare and deliver the

remaining dose from the one syringe

Can prepare 2 equal, separate syringes

64

Attach MAD Tip to Syringe

Suction nasal cavity as needed to clear blood or secretions Clear nasal passages enhance absorption of

medication

Deliver medication in divided doses Maximum of 1 ml per nare

65

Inserting MAD Nasal

Luer tip can be connected to a

variety of syringes

Control the patient’s head with

one hand

Need to prevent movement

Gently but firmly place the MAD

into one nostril Aim upward and toward ear on

same side

Briskly compress the syringe to

deliver the drug as an atomized

mist into nares

66

Dispensing Mist

Must briskly compress

syringe to convert liquid

drug to a fine atomized

mist

Mist results in broader

mucosal coverage; better

chance of absorption into

the blood stream than

drops that can run straight

back into the throat.

67

Ventilatory Support via BVM

Determine need for ventilatory support

Hypoventilation

Apnea

Shallow respirations

Dropping SpO2 levels

Hypercapnia

○ Excessive levels of carbon dioxide (CO2) from

hypoventilation

○ Best monitored by capnography waveform if available

68

Ventilatory Support

Patient has a pulse, needs ventilatory support

Drug overdose

Stroke

Head injury affecting respiratory center

○ Adult 10 breaths per minute – 1 every 6 seconds

○ Child 20 breaths per minute – 1 every 3 seconds

○ Infant <1 y/o 25 breaths per minute – 1 every 2.5

seconds

69

Hazards of Hyperventilation

Hyperventilation causes excessive exhalation

of carbon dioxide (CO2) creating secondary

injuries

Hypocarbia- low levels of CO2

○ Stimulates vasoconstriction which decreases

blood flow

○ Brain especially sensitive to decreased blood flow

○ Decreased levels of oxygen and glucose

70

Lessons Learned in General

It’s amazing what people will put into their bodies!

Patients under the influence have the potential to

become violent

Be diligent to avoid accidental needle sticks to

yourself in this population

Carefully monitor respiratory status and be

prepared to ventilate this patient

Enough Narcan has been administered when the

patient can resume breathing effectively on their

own

71

Questions??

72