Presentation on theme: "Patients Under the Influence"— Presentation transcript:
0International Trauma Life Support, 7e Patients Under the Influence of Alcohol or Drugs20Key Lecture PointsReview commonly abused drugs and their common signs and symptoms.Review clues of drug use by the patient.Review the pertinent history you should obtain when managing a patient who may be under the influence of drugs.Explain how to interact with a patient who is under the influence of drugs.Explain how to manage the patient who is injured, under the influence, and uncooperative. Be familiar with and discuss your local laws regarding restraining a patient.
1Patients Under the Influence Courtesy of Louis B. Mallory, MBA, REMT-P
2Overview Signs and symptoms of under influence of alcohol and/or drugs Five strategies to ensure cooperationSituations to restrain patients and how to handle an uncooperative patientSpecial considerations for assessment and management with substance abuse
3Under Influence Trauma and alcohol or drugs Car crashes involving alcoholSubstance abusers at greater risk of injuryHigh rate of alcohol and drug use in fatalitiesSuspicion of alcohol or drug influenceUse high index of suspicion, physical exam, history, bystanders, evidence at scene to identifyNOTE: Substance abuse includes abuse of alcohol, drugs, or both.Substance abuse is associated with a number of traumatic events, often resulting from accidents, car crashes, suicides, homicides, and other violent crimes.One study found a high rate of alcohol and illicit drug use in patients who die from trauma (Journal of American College of Surgeons).Number of seriously injured trauma patients are under influence of alcohol or some other substance.History supplied by the patient or bystanders can also help to establish whether substance abuse is involved. Obtain history from patient and bystanders, but remember many patients (and bystanders) deny substance use.If possible, inspect patient's surroundings for clues that drugs or alcohol may have been used. Note any alcoholic beverage bottles, pill containers, injection equipment, smoking paraphernalia, or unusual odors.
4Patients Under Influence Unique challenges for managementUnder the influence vs. an emergencyMay need to alter management techniquesMany initially refuse treatmentInteraction and cooperationConsult local protocol, medical direction, and law enforcement for assistanceIt is extremely difficult to differentiate between patients under the influence and those experiencing a medical and/or trauma emergency.
6Mental Status Altered mental status Euphoria Psychosis Paranoia ConfusionDisorientationDue to head injury, shock, hypoglycemia until proven otherwiseRemember that altered level of consciousness is always due to a head injury, shock, or hypoglycemia, until proven otherwise.An altered mental status can be seen in every form of substance abuse.Courtesy of Louis B. Mallory, MBA, REMT-P
7Under Influence Respirations Speech Significantly depressed Slurred Opiates and sedativesSpeechSlurredAlcohol or sedativesRambleHallucinogensCourtesy of Louis B. Mallory, MBA, REMT-P
8Pupils Constricted Dilated Fixed and dilated Opiates Early barbiturate useDilatedAmphetaminesCocaineHallucinogensMarijuanaFixed and dilatedHigh-dose barbituratesCourtesy of Louis B. Mallory, MBA, REMT-P
10Interaction Interaction style influences cooperation Offensive and judgmentalCan cause patients to be uncooperativeCan lengthen on-scene timePositive and nonjudgmentalCan cause patients to be cooperativeEasier assessment with all appropriate interventionsTrauma patients under the influence of alcohol or drugs can challenge the provider not only by their traumatic injuries, but also by their attitudes.The way in which you interact with patients who have abused substances can determine if the patient will be cooperative or uncooperative.How you speak to these patients can be as important as what you are doing for them.
11Interaction Strategies Improving cooperationIdentify yourself and orient patient to surroundingsTreat with respect and avoid being judgmentalAcknowledge concerns and feelingsLet patients know what will be required of themAsk closed-ended questions for historyAsk them their name and how they would like to be addressed. With this patient population, it may be necessary to orient them to place, date, and what is going on. These patients may need to be reoriented frequently.Often, a lack of respect can be heard in tone of your voice or how you say things, not just in what you say.The patient who is scared or confused may be more comfortable with what is taking place if you recognize and address these feelings. Be gentle but firm. Explain all treatment interventions before they are performed.Patients may be confused and not realize that they need to hold still while you are trying to stabilize them on a backboard.Closed-ended questions are questions that can be answered with a yes or no. These patients may only be able to concentrate for short periods of time, and they may ramble when asked open-ended questions that require a full answer. Consider getting as much of history as you can from relatives, friends, or bystanders.
12Uncooperative Patient Interacting with uncooperative patients:Be firmSet limits to behaviorConsider physical restraintOnly if unable to provide adequate careShow of force may be enough
14Patients Under Influence ITLS Primary and Secondary SurveysNote:High risk for infectionLook for clues to substance abuseFinger-stick glucose for altered mental statusCardiac monitoring for altered mental statusHigh-flow oxygen and capnographyHypothermia and hypotension commonITLS approach to patient care will work well, even with patients under the influence of alcohol or drugs.This patient population includes people who are at high risk for infection with hepatitis B, hepatitis C, and HIV.
15Specific TreatmentsIMAGE: Table 20-2 Drug Categories and Specific Treatments to Consider.*Naloxone should be titrated to patient's respirations. Repeated doses may be indicated as narcotic may last longer than effects of naloxone.**Flumazenil use is controversial; it can precipitate seizures in patients dependent on benzodiazepines. Further, flumazenil use may cause seizures in those who have been using benzodiazepines to prevent seizures and in those patients who have overdosed on tricyclic antidepressants. Flumazenil should only be given on direct order of medical direction.
16NIDA 2009 USA Study Teenage drug use decreasing Belief MDMA (ecstasy) not harmfulConcerned with nonmedical use of:Hydrocodone (Vicodin)Oxycodone (OxyContin)Based upon a 2009 survey of teenagers, The National Institute on Drug Abuse (NIDA) concluded that many drug use trends are declining.However, they reported that the perception that the Methylenedioxymethamphetamie MDMA (ecstasy) is harmful is going down and this might be a precursor to an increase in use of this drug.The NIDA also expressed concern about the nonmedical use of the narcotics Vicodin (hydrocodone) and OxyContin (oxycodone).
17Summary Know signs and symptoms of abuse: Recognize patient who may be impairedAttention to specific areas for critical changesProvide lifesaving interventions for substancesInteraction strategies for improving patient cooperation are very importantSafety is primary concernPeople who abuse alcohol and drugs are frequently involved in trauma. Be prepared to treat them often.Determining that your patient has abused some substance will allow you to pay attention to specific areas for critical changes as well as provide lifesaving interventions that may be indicated for individual substances.If you must restrain a patient for his or her safety, do so in a preplanned manner that is most sensitive to your patient's needs.