1 Illicit Drug Emergencies June 2011 CE Condell Medical Center EMS System Site Code #107200E-1211 Prepared by: Lt. William Hoover, Medical Officer Wauconda Fire District Reviewed/revisions by: Sharon Hopkins RN, BSN, EMT-P

2 Objectives Upon successful completion of this module, the EMS provider will be able to: 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.

3 Objectives cont’d 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.

4 Objectives cont’d Describe transport issues regarding the patient who has overdosed. Review the reconstitution of glucagon. Review the use of the MAD device. Review and return demonstrate ventilatory rates using the BVM. Actively participate in discussion of cases of street drug abuse. Successfully complete the post quiz with a score of 80% or better.

5 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

6 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

7 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

8 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

9 Poison Control Center 24 0 per day/7 days per week

10 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

11 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!

12 Alcohol cont’d < 0.08 (80) - legal limit in Illinois 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

13 Alcohol cont’d 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

14 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

15 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

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 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

20 Black Tar Heroin

21 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, O 2, & monitor

22 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

23 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

24 Heroin…

25 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

26 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

27 Cocaine

28 Crack Cocaine

29 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

30 Cocaine: Myocardial Effect Regular use of cocaine increases risk of AMI Increased heart rate and B/P results in increased myocardial O 2 demand Accelerates coronary atherosclerosis process May also induce coronary artery spasms During withdrawal, may have increased incidence of ST elevation indicating acute MI

31 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

32 Cocaine: Agitated Delirium Common in patients dying from cocaine toxicity – Bizarre and violent behavior – Aggression/combativeness – Hyperactivity/unexpected strength – Hyperthermia – Extreme paranoia – Followed by cardiac arrest!

33 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

34 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

35 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

36 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

37 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

38 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

39 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

40 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

41 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

42

43 Crystal Meth

44 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

45 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

46 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, O 2, & EKG – Important to monitor EKG continuously due to potential cardiac issues

47 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.

48 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.

49 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.

50 Meth Labs – A Dangerous Place Typical products used Explosive environments

51 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

52 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

53 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

54 Ecstasy

55 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

56 Ecstasy: Treatment Normal scene safety precautions ABC’s IV, O 2, and EKG monitor Monitor temperature

57 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®

58 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

59 Region X SOP 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

60 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 (CO 2 ) levels – Evaluates effectiveness of ventilations – Evaluates effectiveness of CPR – Can determine return of spontaneous circulation (ROSC) during CPR

61 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

62 Review of Region X 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?

63 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

64 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

65 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 nares is 1 ml – Use equal divided doses per nares

66 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 nares Acceptable to use one syringe and deliver half the dose into one nares, then place the same MAD tip into the 2 nd nares and deliver the remaining dose from the one syringe Can prepare 2 equal, separate syringes

67 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 nares

68 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

69 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.

70 Ventilatory Support via BVM Determine need for ventilatory support – Hypoventilation – Apnea – Shallow respirations – Dropping SpO 2 levels – Hypercapnia Excessive levels of carbon dioxide (CO 2 ) from hypoventilation Best monitored by capnography waveform if available

71 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

72 Hazards of Hyperventilation Hyperventilation causes excessive exhalation of carbon dioxide (CO 2 ) creating secondary injuries – Hypocarbia- low levels of CO 2 Stimulates vasoconstriction which decreases blood flow – Brain especially sensitive to decreased blood flow » Decreased levels of oxygen and glucose

73 Case Scenarios Break into smaller groups Read the following case presentations Be prepared to discuss with the group – General impression with supporting material – Treatment/interventions required – Specific on-going assessment What specifically should be monitored for based on your general impression and patient presentation

74 Case Scenario #1 You are called to the scene for a 45 y/o female who is hard to arouse She has a pulse and is breathing 6 times per minute and shallow Family states patient has taken Valium for years and also has a drinking problem VS: 144/90; P - 82; R – 6 and shallow; SpO 2 92%; skin cool and dry; pale Responds to tactile stimuli

75 Case Scenario #1 S: found unresponsive by family A: none M: valium for anxiety, antihypertensive P: anxiety, high blood pressure L: breakfast this morning E: has been depressed and moping about; recently lost her job and has increased family stress

76 Case Scenario #1 General impression: Overdose Valium mixed with alcohol Interventions – Immediate support of ventilations via BVM One breath every 6 seconds – Monitor for aspiration potential – IV-O 2 -Monitor – Blood glucose level (72) – Consider Narcan Patient may have taken unknown substance(s) No effect on Valium or alcohol if that is all that was ingested

77 Case Scenario #1 Lessons learned Narcan works on narcotics Heroin and methadone are narcotics Valium and Versed are benzodiazepines Valium alone is rarely lethal Valium, when taken in large doses and mixed with alcohol, could prove lethal Aspiration precautions must be considered Increased morbidity associated with aspiration Prevented with diligent monitoring, having suction available, having patient secured to backboard that can be rapidly turned to the side

78 Case Scenario #2 You are called to the scene 35 y/o female who is unresponsive Patient found in bed unresponsive; eyes flicker open when name called; moaning and groaning; localizes to pain (pushes you away) VS: 110/60; P-82; R-16; SpO 2 92% Cardiac monitor shows normal sinus rhythm Lung sounds clear bilaterally; normal respiratory effort; skin warm and dry

79 Case Scenario #2 S: Found in bed unresponsive A: unknown M: Metoprolol, Xanax, Zoloft, Ativan, Advair, Pepcid P: unavailable (what do the meds indicate?) – Do know this patient has overdosed before L: possibly last night E: made verbal threats several hours ago that she wanted to hurt herself What is the GCS?

80 Case Scenario #2 Medical history: hypertension, anxiety, depression, asthma, ulcer GCS: = total 10 Blood glucose level 127 Interventions – IV-O 2 -monitor – Narcan 2 mg What routes can be used? – IN, IV, IM Remember that IN is a good first line route while waiting to establish an IV

81 Case Scenario #2 Lessons learned: How much Narcan is enough? – The patient does not need to be woken up – If there is depressed respirations, the goal is to lighten the patient enough that they can breath on their own This patient takes a variety of Benzodiazepine drugs – Will Narcan be effective? No; only effective against narcotics – Patients often mix drugs and do not even know what they have taken

82 Case Scenario #3 You are called to the scene of an underground party at a local & deserted farm Dispatch informs you there are 2 people not breathing As you find your 2 patients, you are informed that there are more patients spread throughout the scene that have altered level of consciousness or are unresponsive What do you do???

83 Case Scenario #3 Immediately call for additional EMS crews Confirm police are on the scene Begin to triage patients Sounds like patients, at minimum, will need supportive ventilations – Via BVM deliver 1 breath every 6 seconds – Protect the airway Watch for vomiting Have suction available Be prepared to turn patient to their side

84 Case Scenario #3 Group discussion for use of resources: – If you have enough BVM’s but not enough crew members for every patient, what could you do? How would you recruit additional help to ventilate patients? (ie: other party goers, police, who???) – If you do not have enough suction units to be used one-on-one, what could you do to prevent aspiration? Go back to basics – positioning patient (side lying)

85 Case Scenario #4 You have a 36 y/o male who is a walk-in Patient complains of palpitations, is anxious and states he feels like he is going to die Patient is diaphoretic, tachycardic, and can’t sit still – B/P 188/100; P – 140; R – 36 What is your general impression? – Cardiac patient until proven otherwise – Considering the age and presentation, you need to consider cocaine ingestion

86 Case Scenario #4 You have started ALS care on this patient – IV – O 2 – Monitor – Interpretation? Sinus tachycardia – Any other interventions you would initiate? Possibly aspirin, denies chest pain so no nitroglycerin at this point

87 Case Scenario #4 During the call you now observe the following on the monitor: Impression? – ST elevation (only evident on Lead II for now) – Need to obtain a 12 lead EKG – Update report to Medical Control

88 Case Scenario #4 Impression of 12 lead EKG? Inferior wall MI – ST elevation II, III, aVF

89 Case Scenario #4 Treatment for this patient now? – Reevaluate patient Vital signs, pain scale, complete history if not previously obtained – Ask about use of illicit drugs (ie: cocaine) Aspirin – if not previously administered Nitroglycerin if chest pain is present, blood pressure adequate, and no Viagra use

90 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

91 Bibliography Lynn Barkley Burnett, MD (March 19, 2010) Street Drugs; Publishers Group; Long Lake, MN Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practice. Brady US Dept of Justice. Drugs of Abuse Edition