1. TRANSITION SERIES Topics for the Advanced EMT CHAPTER Toxicology: Street Drugs 27

2. Objectives Discuss the frequency of abused drugs in the U.S. Recognize how to recognize street drugs by assessment patterns. Discuss assessment findings and management for a patient suffering from a street drug overdose.

3. Introduction Drug use was, at one time, almost exclusive to large metro areas. Drug use is now seen in rural areas and in all socioeconomic classes. Mixing of illegal drugs has also gained popularity.

4. Epidemiology The National Survey on Drug Use and Health (NSDUH) reports over 19.9 million Americans ages 12 and older used illegal drugs within the month of survey in 2007. Highest bracket—18-20 year olds.

5. Epidemiology (cont’d) Most commonly abused drugs in descending order: marijuana, psychotropics, cocaine, hallucinogens, inhalants, and heroin.

6. Pathophysiology (cont’d) Too many drugs and drug names to possibly know them all.

7. Pathophysiology (cont’d) Learn to recognize a “toxidrome,” which refers to how the drug is affecting the body. –Uppers –Downers –Narcotics –Mind-altering –Volatile chemicals

8. Commonly Abused Drugs

9. Pathophysiology (cont’d) Stimulants –Profound effect on body that imitates the sympathetic nervous system. –HTN, tachycardia, pupil dilation, temp elevation, trembling. –Patient may experience a hypertensive crisis, an MI, or even seizures. –Patient may also be combative, aggressive, or delirious.

10. Pathophysiology (cont’d) Depressants (narcotics and sedatives) –Lowering of bodily activities. –Brain stem depression. –HR drops, blood pressure drops, respirations drop. –Orientation diminishes, muscle tone goes lax. –Pupillary constriction common.

11. Pathophysiology (cont’d) Cannabis products –Both psychological and physiological effects. –Changes in perception. –Mood swings. –Disturbed short-term memory. –Heart rate elevates, B/P drops.

12. Pathophysiology (cont’d) Hallucinogens –Agents that change perceptions of reality. –Patient “hears” and “sees” things that are not part of reality. –Distortions to shapes, colors, sounds. –Hemodynamically they are usually stable, but mentally they have disturbances.

13. Pathophysiology (cont’d) Inhalants –Volatile in nature, they are sniffed or inhaled. –Many agents are found in home products. –Damage may also occur to mucous membranes and lung tissue.

14. Pathophysiology (cont’d) Inhalants –Many of these agents displace oxygen and the patient has confusion, coma, seizures, heart failure, or even pulmonary edema.

15. Pathophysiology (cont’d) Alcohol –Brain is the first organ affected with ingestion. –Initial feeling of euphoria with subsequent depression and impairment of cognition and other abilities. –Great risk for vomiting and aspiration.

16. Assessment Findings General considerations –Use dispatch information. –Always protect yourself from harm. –Clues at the scene may point to drug abuse. –Learn to recognize not the drug itself, but what toxidrome it fits into.

17. A variety of substances may be abused.

18. Emergency Medical Care Ensure an open airway. Provide supplemental oxygen. Position the patient (consider blood pressure and potential for aspiration). Determine blood glucose level.

19. Emergency Medical Care (cont’d) Consider use of 1g/kg activated charcoal if situation is appropriate. If narcotic (opioid) overdose is suspected, administer naloxone 0.4-2.0 mg titrated to respiratory effort. Provide rapid transport to ED.

20. Case Study You are called to a party where several underage teenagers were reportedly drinking and doing drugs (per neighbor who summoned PD and EMS). Upon your arrival, a patient is found unresponsive on the porch with gurgling respirations that are slow. PD is already on the scene.

21. Case Study (cont’d) Scene Size-Up –Standard precautions taken. –16–17-year-old male, normal weight. –No sign of struggle or trauma. –Patient lying supine, looks unresponsive. –NOI is “unknown medical.” –PD on scene, no additional resources needed.

22. Case Study (cont’d) Primary Assessment Findings –Patient unconscious to noxious stimuli. –Gurgling sounds coming from airway. –Breathing is slow and shallow. –Carotid pulse feels slow, peripheral pulse absent. –No signs of bleeding or trauma. –No one on scene seems to “know” this person.

23. Case Study (cont’d) Is this patient a high or low priority? What life threats, if any, is this patient presenting with? What interventions are warranted at this time?

24. Case Study (cont’d) Medical History –Unknown Medications –Unknown Allergies –Unknown

25. Case Study (cont’d) Pertinent Secondary Assessment Findings –Patient unresponsive to noxious stimuli. –Airway now clear, breathing slow at 6/min. –No alveolar breath sounds, no peripheral pulse. –Pulse oximeter reads 88% on room air.

26. Case Study (cont’d) Pertinent Secondary Assessment Findings –Skin cool, dry, ashen in color. –B/P unobtainable, HR 122/min, RR 6/min. –Pupils pinpoint and nonreactive.

27. Case Study (cont’d) What would be your differentials with this type of overdose? What is your final differential for the type of toxidrome? Relate the vital signs to the category of toxidrome.

28. Case Study (cont’d) Care provided: –Spinal immobilization as a precaution. –High-flow oxygen via PPV @ 10/min. –Ongoing pulse oximeter reading and BGL testing. –Supine positioning. –Narcan administration

29. Summary Drug abuse is still on the rise in many regions and profiles of individuals in the U.S. So many drugs are now abused, the Advanced EMT may want to focus on recognizing the toxidrome itself, not the specific agent.

30. Summary (cont’d) Management must be geared toward the toxidrome, and supportive of any lost bodily function.