Illicit Drug Emergencies ECRN Mod II CE Condell Medical Center EMS System 2 hours CE Credit Site Code #107214E-1211 Prepared by: Lt. William Hoover, Medical Officer Wauconda Fire District Reviewed/revisions by: Sharon Hopkins RN, BSN, EMT-P

Objectives Upon successful completion of this module, the ECRN 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.

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 field treatment options for patients who are under the influence of street drugs and toxic substances.

Objectives cont’d Describe use of restraints in the patients who has overdosed. Review the reconstitution of glucagon. Understand the use of the MAD device. List the ventilatory rates using the BVM. Review cases of street drug abuse. Successfully complete the post quiz with a score of 80% or better.

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 Intentional poisonings and overdoses can be due to illicit drug use, alcohol abuse, and attempted suicide.

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

Definition of Terms Substance/drug abuse Drug dependence/addiction 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

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 EMS can contact them from the field

Poison Control Center 240per day/7 days per week 1-800-222-1222

Routes of Exposure Ingestion Inhalation Topical Injection 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

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! *BAC – Blood alcohol concentration/content BAC – blood alcohol level

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

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

Commonly Abused Depressant Drugs Narcotics/opiates CNS depression Heroin Hydromorphine Darvon, Darvocet Fentanyl 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

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

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).

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 Fentanyl is a synthetic narcotic. Has been often mixed with less potent heroin so buyer still gets same feelings. Has been sold as heroin due to it’s potency.

Heroin

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

Black Tar Heroin

Treatment of Heroin Environmental safety ABC’s IV, O2, & monitor 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

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

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 Narcan Administration of 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

Narcan (naloxone) Narcotic antagonist Used to reverse opioid depression including respiratory depression May precipitate withdrawal Watch for seizure induced activity Field dosing 2 mg IN/IV/IO; repeated to 10 mg max In the field in absence of IV site, can be given via MAD (IN) Give enough to reverse respiratory depression

Heroin… http://youtu.be/Hj6NvwDLjAE http://youtu.be/6mSq69FT3jM

Fentanyl (Duragesic Patch) Synthetic opioid narcotic – highly abusive drug Used for pain control 100 times more effective than Morphine Can cause respiratory depression Reversible with Narcan, supported with BVM Field administration route Can be given IVP/IO/IN Less nausea complaints than morphine Less cardiovascular effects (ie: less ↓ B/P)

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

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

Cocaine

Crack Cocaine

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

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 AMI – acute myocardial infarction

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

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!

Cocaine: Restraints Restraints have been implicated as a contributing factor for user deaths during restraint use with patient lying prone Sudden death appears to have been induced by a combination of three factors that increases oxygen demand and decreases oxygen delivery See next slide

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

Cocaine: Treatment Make certain the environment 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

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

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 Vasopressin offers theoretical advantage over Epi. 2005 AHA Guidelines recommend avoiding high dose epi. 39

Benzodiazepines Tranquilizers Valium® Librium® Xanax® Halcion® Ativan® Diazepam (Valium®) may be fatal when mixed with alcohol, opiates, and other depressants Respiratory depression →resp arrest Nearly impossible to take a fatal dose of Valium® when not mixed with any other product, especially alcohol

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

Methamphetamine To control production of methamphetamine from over-the-counter products, controls put 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

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

Crystal Meth

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

Crystal Meth: Signs & Symptoms Dilated pupils Dry mouth Euphoria Decreased appetite Rapid speech Irritability/Argumentative Depression Nasal congestion Insomnia Weight loss Increased HR, BP & Temperature Restlessness No interest in food or sleep. Violence Paranoia

Crystal Meth: Treatment Scene safety extremely important for EMS 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

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.

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.

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.

Meth Labs – A Dangerous Place Typical products used Explosive environments

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

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

Ecstasy: Background Is taken orally – pill form with multiple logos May cause psychological addiction Polydrug use often involved Mix of a variety of chemicals taken simultaneously 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

Ecstasy

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

Ecstasy: Treatment Normal scene safety precautions ABC’s IV, O2, and EKG monitor Monitor temperature

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®

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

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

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

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

Review of Region X Equipment Do you know how to reconstitute Glucagon? Do you know how medication is delivered via the MAD device? Do you know the ventilation rate if you have to support a patient’s ventilations?

Glucagon Reconstitution Glucagon must be reconstituted prior to administration Supplied in vials 1 unit of powder/disk generally in compressed form 1 ml of diluting solution

Glucagon Administration Draw up the diluent and add to vial with powder/disk Cleanse off vial tops with alcohol wipe Once the diluent has been added to the powder/disk, gently roll the vial to mix the contents Check that all particles have been fully dissolved prior to drawing up the medication Inject glucagon as an IM Aspiration is performed to check for potential and inadvertent entry into a blood vessel. If blood is returned, withdraw the needle, dispose of the equipment and begin again. Do not inject the bloody material into the patient; this is an irritant with the blood mixed in.

Glucagon Administration If Glucagon IM given in absence of IV access, then an IV is established, repeat blood sugar level If blood sugar level remains low and patient remains with altered level of consciousness, Dextrose is to be administered Glucagon is a hormone to trigger release of stored glucose (if there is any present) Dextrose is the sugar Brain very sensitive to sugar levels

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 Doses divided equally per nares Medication delivered nasally is absorbed directly into the bloodstream avoiding first pass through the liver which could alter the medication.

Delivering Medication via MADD 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 2nd nares and deliver the remaining dose from the one syringe Must be dispensed rapidly to create a mist If delivered too slowly, medication dribbles out The MAD tip fits onto the end of the prefilled Narcan syringe so no drawing up is required.

Attach MAD Tip to Syringe Suction nasal cavity as needed to clear blood or secretions Clear nasal passages enhance absorption of medication Medication delivered in divided doses Maximum of 1 ml per nares

Inserting MAD Nasal Luer tip can be connected to a variety of syringes Patient’s head controlled with one hand Need to prevent movement MAD tip gently but firmly placed into one nostril Tip aimed upward and toward ear on same side Syringe compressed briskly to deliver the drug as an atomized mist into nares Can connect the MAD tip to the prefilled syringe and instill 1 ml into the 1st nostril and then move to the 2nd nostril to instill the other 2 ml of Narcan. Consider drawing up half the dose, administer, and draw up rest of dose to administer into 2nd nostril if using one syringe. With the liquid in the syringe, you have control over pushing the medication that a mist is created without overshooting the volume you want to instill.

Dispensing Mist Must briskly compress syringe to convert liquid 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. If using one syringe, must be careful to limit volume to 1 ml per nares.

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

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

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 Secondary injuries are those occurring after the primary insult. Can be the result of care provided or care withhold and a consequence of the patient’s response to their condition/injuries.

Case Scenarios Read the following case presentations Determine: 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

Case Scenario #1 EMS was 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; SpO2 92%; skin cool and dry; pale Responds to tactile stimuli A patient that responds to tactile stimuli is considered to be responding to painful stimuli. Pain does not always have to be inflicted.

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

Case #1 - EMS Orders From ECRN What needs to be done to support ventilations? Is a blood glucose level necessary? What diagnostic medication is indicated?

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-O2-Monitor Blood glucose level (72) Obtain on all patients with altered mental status Consider Narcan Patient may have taken unknown substance(s) No effect on Valium or alcohol if that is all that was ingested

Case Scenario #1 Lessons learned Narcan works on narcotics Heroin, methadone, & Fentanyl 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

Case Scenario #2 EMS was 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; SpO2 92% Cardiac monitor shows normal sinus rhythm Lung sounds clear bilaterally; normal respiratory effort; skin warm and dry

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 Medications taken for: blood pressure, anxiety, antidepressant, anxiety, asthma, and GI ulcers

Case #2 – EMS Orders From ECRN What is the GCS? If blood glucose level indicated? What diagnostic medication is indicated? What routes can this medication be given?

Case Scenario #2 Medical history: hypertension, anxiety, depression, asthma, ulcer GCS: 3-2-5 = total 10 Altered mental status - Blood glucose level 127 Interventions IV-O2-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

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

Case Scenario #3 EMS was called to the scene of an underground party at a local & deserted farm Dispatch informs EMS there are 2 people not breathing As EMS finds their 2 patients, they are informed that there are more patients spread throughout the scene that have altered level of consciousness or are unresponsive How would EMS handle the scene?

Case Scenario #3 EMS Response 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

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

Case Scenario #3 What impact could this have on the ED? Consider activation of you hospital disaster plan The Resource Hospital may need to help coordinate disposition of patients from the field Where would you recruit enough staff to assist with managing the airways for these patients?

Case Scenario #4 EMS has 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 the general impression? Cardiac patient until proven otherwise Considering the age and presentation, consider cocaine ingestion

Case Scenario #4 EMS has started ALS care on this patient IV – O2 – Monitor Interpretation? Sinus tachycardia Any other interventions to initiate? Possibly aspirin, denies chest pain so no nitroglycerin at this point

Case Scenario #4 During the call EMS now observes the following on the monitor: Impression? ST elevation (only evident on Lead II for now) A 12 lead EKG needs to be obtained; transmitted if possible Update reported to Medical Control

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

Case Scenario #4 EMS treatment for this patient now? ECRN response Patient reevaluated 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 ECRN response Follow ED protocol to activate cardiac alert

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

Bibliography http://emedicine.medscape.com; Lynn Barkley Burnett, MD (March 19, 2010) 2010 Street Drugs; Publishers Group; Long Lake, MN. http://www.drugabuse.gov http://www.crystalmethaddiction.org http://www.illinoisattorneygeneral.gov http://www.emsvillage.com/articles/article.cfm?id=2146 www.streedrugs-university.org www.DEA.GOV www.drugidbible.com http://youtu.be/Hj6NvwDLjAE http://youtu.be/6mSq69FT3jM Bledsoe, B., Porter, R., Cherry, R. Paramedic Care Principles & Practice. Brady. 2009. US Dept of Justice. Drugs of Abuse. 2005 Edition