1. Alcohol Substance Abuse 1

2. Incidence of Illicit Drug Emergencies There is a high potential for EMS involvement in illicit drug emergencies There is a high potential for EMS involvement in illicit drug emergencies National Institute on Drug Abuse keeps data National Institute on Drug Abuse keeps data 14.5 million people use illicit drugs regularly 14.5 million people use illicit drugs regularly 20 million people have tried cocaine 20 million people have tried cocaine 860,000 people use cocaine weekly 860,000 people use cocaine weekly 11.6 million people use marijuana regularly 11.6 million people use marijuana regularly 770,000 people use hallucinogens (ie: LSD, PCP) regularly 770,000 people use hallucinogens (ie: LSD, PCP) regularly 2.5 million people have used heroin 2.5 million people have used heroin 2

3. Illicit Drug Behavior Substance abusers are 18 times more likely to be involved in criminal activity Substance abusers are 18 times more likely to be involved in criminal activity Violent crimes and thefts to support drug habits Violent crimes and thefts to support drug habits Drug overdoses Drug overdoses Accidental Accidental Miscalculation of dosing Miscalculation of dosing Changes in strength of drug Changes in strength of drug Suicide attempt Suicide attempt Polydrug use Polydrug use Recreational drug use Recreational drug use 3

4. Definition of Terms Substance/drug abuse Substance/drug abuse Use of pharmacological substances for purposes other than a medically defined reason Use of pharmacological substances for purposes other than a medically defined reason Drug dependence/addiction Drug dependence/addiction A craving for the drug, an overwhelming feeling of the need to obtain and continue to use the drug A craving for the drug, an overwhelming feeling of the need to obtain and continue to use the drug Tolerance Tolerance The need for increasingly higher amounts of the drug to get the same effects The need for increasingly higher amounts of the drug to get the same effects Withdrawal Withdrawal A psychological or physical reaction when the substance is stopped 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 Most signs and symptoms of withdrawal are the exact opposite of what exposure to the substance causes 4

5. Poison Control Centers Set up to assist in treatment of poison victims Set up to assist in treatment of poison victims Provides information on new products and new treatment approaches Provides information on new products and new treatment approaches Staffed with trained experts 24/7 Staffed with trained experts 24/7 Information updated regularly Information updated regularly Consultation can assist in determining potential toxicity to the patient Consultation can assist in determining potential toxicity to the patient Can provide definitive treatment information that should be started Can provide definitive treatment information that should be started 5

6. Routes of Exposure Ingestion Ingestion Can cause immediate or delayed effects Can cause immediate or delayed effects Inhalation Inhalation Rapid absorption via alveoli in the lungs Rapid absorption via alveoli in the lungs Topical Topical Entry across the skin or mucous membranes Entry across the skin or mucous membranes Injection Injection Can cause immediate and delayed effects Can cause immediate and delayed effects 6

7. Commonly Abused Depressant Drugs Alcohol Alcohol CNS depressant CNS depressant Binge drinking equals BAC > 0.08 (80) Binge drinking equals BAC > 0.08 (80) Men – typically 5+ drinks in 2 hours Men – typically 5+ drinks in 2 hours Women – typically 4+ drinks in 2 hours Women – typically 4+ drinks in 2 hours Alcohol poisoning Alcohol poisoning Affects the respiratory center in the brain Affects the respiratory center in the brain Vomiting leads to aspiration & asphyxiation Vomiting leads to aspiration & asphyxiation Sobering up Sobering up Need time Need time Caffeine does not help – really! Caffeine does not help – really! 7

8. Alcohol continued < 0.08 (80) - legal limit in California < 0.08 (80) - legal limit in California 0.30 (300) – stupor, passed out, difficult to awaken 0.30 (300) – stupor, passed out, difficult to awaken 0.35 (350) – typical for coma 0.35 (350) – typical for coma 0.40 (400) – coma, possibly death due to respiratory arrest 0.40 (400) – coma, possibly death due to respiratory arrest 8

9. Alcohol continued BAC continues to rise even after passing out BAC continues to rise even after passing out Alcohol in the stomach and intestines continues to enter the blood stream Alcohol in the stomach and intestines continues to enter the blood stream A fatal dose can be ingested before becoming unconscious A fatal dose can be ingested before becoming unconscious General signs/symptoms General signs/symptoms Mental confusion Mental confusion Vomiting Vomiting Seizures – often related to hypoglycemia Seizures – often related to hypoglycemia Slow/irregular breathing Slow/irregular breathing Hypothermia Hypothermia 9

10. Alcohol Withdrawal With abrupt cessation of alcohol after prolonged ingestion, there is an overreaction of the brain and other mechanisms With abrupt cessation of alcohol after prolonged ingestion, there is an overreaction of the brain and other mechanisms Early symptoms can start 6-8 hours after last drink Early symptoms can start 6-8 hours after last drink Delirium Tremons can last 2-7 days Delirium Tremons can last 2-7 days Treatment is benzodiazepines and possibly ICU admission Treatment is benzodiazepines and possibly ICU admission SEIZURE PRECAUTIONS SEIZURE PRECAUTIONS 10

11. Commonly Abused Depressant Drugs Narcotics/opiates Narcotics/opiates CNS depression CNS depression Heroin Heroin Hydromorphine Hydromorphine Darvon, Darvocet Darvon, Darvocet Heroin – most abused of the narcotics Heroin – most abused of the narcotics Physical and psychological dependence Physical and psychological dependence Addiction and physical tolerance Addiction and physical tolerance Mood swings, severe constipation Mood swings, severe constipation Menstrual irregularities Menstrual irregularities Lung damage, skin infections Lung damage, skin infections Seizures, unconsciousness, coma Seizures, unconsciousness, coma 11

12. Narcotics Typical signs and symptoms Typical signs and symptoms Pinpoint pupils Pinpoint pupils No physical pain; rush of pleasurable feelings No physical pain; rush of pleasurable feelings Lethargic, drowsy, slurred speech Lethargic, drowsy, slurred speech Shallow breathing Shallow breathing Sweating, vomiting Sweating, vomiting Hypothermia Hypothermia Sleepiness Sleepiness Loss of appetite Loss of appetite 12

13. Heroin: Background Heroin comes from opium poppy capsules. Heroin comes from opium poppy capsules. Heroin is usually injected, but it can be sniffed, snorted or smoked. Heroin is usually injected, but it can be sniffed, snorted or smoked. Typical heroin user injects up to 4 times a day. Typical heroin user injects up to 4 times a day. Intravenous injection provides greatest intensity and rapid onset (7-8 seconds). Intravenous injection provides greatest intensity and rapid onset (7-8 seconds). IM injection produces a slower response (5-8 minutes). IM injection produces a slower response (5-8 minutes). 13

14. Heroin: Background White powdery substance White powdery substance Heroin enters the brain, where it is converted to morphine Heroin enters the brain, where it is converted to morphine Due to needle use, heroin users are at risk for: Due to needle use, heroin users are at risk for: HIV HIV Hepatitis-C Hepatitis-C Other bloodborne pathogens Other bloodborne pathogens NEW TREND: mixing heroin & fentanyl NEW TREND: mixing heroin & fentanyl Increases number of deaths from respiratory depression Increases number of deaths from respiratory depression 14

15. 15 Heroin

16. Black Tar Heroin Is produced in Mexico Is produced in Mexico Color and consistency of tar resulting from crude processing Color and consistency of tar resulting from crude processing Most frequently dissolved, diluted, and injected 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 It’s unlikely a white powder heroin user will switch to black tar heroin unless there is a significant supply interruption 16

17. 17 Black Tar Heroin

18. Treatment of Heroin Scene Safety Scene Safety Due to the increased risk for Bloodborne Pathogens, PPE is extremely important 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! 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 This population has a high incidence of HCV and HIV ABC’s ABC’s IV, O 2, & monitor IV, O 2, & monitor 18

19. Treatment of Heroin Watch for pulmonary edema Watch for pulmonary edema In some heroin overdoses this can occur In some heroin overdoses this can occur Respiratory support early! Respiratory support early! Ventilate at a rate of 10 breaths per minute Ventilate at a rate of 10 breaths per minute 1 breath every 6 seconds 1 breath every 6 seconds 19

20. Treatment of Heroin Narcan quickly reverses the effects of heroin on the CNS (usually within 5 minutes) 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 Generally, these patients are not pleased to have their “high” wiped out by our Narcan May cause withdrawal symptoms including seizures May cause withdrawal symptoms including seizures If large doses of heroin were used, there could be a relapse when the Narcan wears off 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 may be shorter acting based on dose of heroin taken 20

21. Heroin… http://youtu.be/Hj6NvwDLjAE http://youtu.be/Hj6NvwDLjAE http://youtu.be/Hj6NvwDLjAE 21

22. Cocaine: Background A central nervous system stimulant A central nervous system stimulant Two forms Two forms Powder that can be snorted or dissolved in water and injected 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 Crack that comes in a rock crystal form that can be heated and the vapors smoked Effects occur more rapidly than cocaine Effects occur more rapidly than cocaine Effects more intense than cocaine Effects more intense than cocaine Effects do not last as long as cocaine Effects do not last as long as cocaine 22

23. Cocaine: Background Cocaine is the most potent stimulant of natural origin Cocaine is the most potent stimulant of natural origin One of the oldest identified drugs One of the oldest identified drugs Coca leaves (source of cocaine) have been ingested for thousands of years 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 Is not used medically today due to high potential for abuse and addiction 23

24. 24 Cocaine

25. 25 Crack Cocaine

26. Cocaine: Pathophysiology Cocaine related dysrhythmic fatalities occur in patients with low or moderate levels of cocaine use Cocaine related dysrhythmic fatalities occur in patients with low or moderate levels of cocaine use Tachydysrhythmias most common Tachydysrhythmias most common Hearts of cocaine users are 10% heavier than non- cocaine users Hearts of cocaine users are 10% heavier than non- cocaine users Increase QRS voltage indicative of ventricular enlargement Increase QRS voltage indicative of ventricular enlargement Conduction delays resulting in widening of the QRS and prolonged QT segment Conduction delays resulting in widening of the QRS and prolonged QT segment 26

27. Cocaine: Myocardial Effect Regular use of cocaine increases risk of AMI Regular use of cocaine increases risk of AMI Increased heart rate and B/P results in increased myocardial O 2 demand Increased heart rate and B/P results in increased myocardial O 2 demand Accelerates coronary atherosclerosis process Accelerates coronary atherosclerosis process May also induce coronary artery spasms May also induce coronary artery spasms During withdrawal, may have increased incidence of ST elevation indicating acute MI During withdrawal, may have increased incidence of ST elevation indicating acute MI 27

28. Cocaine: Signs & Symptoms Dilated pupils Dilated pupils Hyperactivity Hyperactivity Euphoria Euphoria Irritability Irritability Anxiety Anxiety Excessive talking Excessive talking Depression or excessive sleeping Depression or excessive sleeping Long periods without eating or sleeping Long periods without eating or sleeping Weight loss Weight loss 28 Paranoia Paranoia Dry mouth/nose Dry mouth/nose Tachycardia Tachycardia Hypertension Hypertension Disturbance of heart rhythm Disturbance of heart rhythm Chest pain Chest pain Heart failure Heart failure Respiratory failure Respiratory failure Strokes/seizures Strokes/seizures

29. Cocaine: Agitated Delirium Common in patients dying from cocaine toxicity Common in patients dying from cocaine toxicity Bizarre and violent behavior Bizarre and violent behavior Aggression/combativeness Aggression/combativeness Hyperactivity/unexpected strength Hyperactivity/unexpected strength Hyperthermia Hyperthermia Extreme paranoia Extreme paranoia Followed by cardiac arrest! Followed by cardiac arrest! 29

30. Cocaine: Restraints Restraints have been implicated as a contributing factor for user deaths during prone restraint 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 Sudden death appears to have been induced by a combination of three factors that increases oxygen demand and decreases oxygen delivery See next slide See next slide 30

31. 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 31

32. Cocaine: Treatment Make certain the scene is safe 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 Not only is there potential for your patient to become violent, but for bystanders that may be users as well Establish ABC’s Establish ABC’s Oxygen Oxygen EKG (12-lead) and monitor continuously EKG (12-lead) and monitor continuously IV of Normal Saline at TKO unless need for volume is indicated IV of Normal Saline at TKO unless need for volume is indicated 32

33. Cocaine: Treatment Frequent vital signs with temperature levels Frequent vital signs with temperature levels Monitor temperature often; may continue to rise Monitor temperature often; may continue to rise Obtain glucose level Obtain glucose level Use Narcan carefully in patients with altered mental status Use Narcan carefully in patients with altered mental status If safe to do so, avoid restraints as this could cause risks associated with hyperthermia If safe to do so, avoid restraints as this could cause risks associated with hyperthermia Remove any residual cocaine from nares Remove any residual cocaine from nares Protect your skin from potential absorption Protect your skin from potential absorption 33

34. Cocaine: Cardiac Arrest Concerns Epinephrine Epinephrine Hyper-adrenergic state caused by cocaine increases myocardial oxygen demand. Hyper-adrenergic state caused by cocaine increases myocardial oxygen demand. Epinephrine has the same effect Epinephrine has the same effect Cocaine frequently causes acidosis Cocaine frequently causes acidosis Epinephrine loses much effectiveness in an acidotic environment Epinephrine loses much effectiveness in an acidotic environment Benzodiazepines Benzodiazepines Benzodiazepines (ie: Valium®, Versed®) are used to control seizure activity Benzodiazepines (ie: Valium®, Versed®) are used to control seizure activity 34

35. Benzodiazepines Tranquilizers Tranquilizers Valium® Valium® Librium® Librium® Xanax® Xanax® Halcion® Halcion® Ativan® Ativan® Diazepam (Valium ® ) may be fatal when mixed with alcohol, opiates, and other depressants 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 Nearly impossible to take a fatal dose of Valium® when not mixed with any other product, especially alcohol 35

36. Amphetamines Stimulant Stimulant Benzedrine Benzedrine Dexedrine Dexedrine Ritalin Ritalin Used by prescription to treat attention deficit hyperactivity disorder (ADHD) Used by prescription to treat attention deficit hyperactivity disorder (ADHD) Ephedrine and pseudoephedrine a component in cold preparation medications Ephedrine and pseudoephedrine a component in cold preparation medications Used as decongestant Used as decongestant Used for illicit manufacture of methamphetamine Used for illicit manufacture of methamphetamine 36

37. Methamphetamine To control production of methamphetamine from over-the-counter products, controls in place To control production of methamphetamine from over-the-counter products, controls in place Sales of products restricted Sales of products restricted Limited quantities purchased for every 30 days Limited quantities purchased for every 30 days Must be of a minimum age Must be of a minimum age Must show proper identification Must show proper identification Above controls have contributed to decrease in meth labs Above controls have contributed to decrease in meth labs 37

38. Crystal meth: Background Dates back to WW II to reduce fatigue and suppress appetite Dates back to WW II to reduce fatigue and suppress appetite Crystal Meth is typically smoked like crack cocaine Crystal Meth is typically smoked like crack cocaine Can also be ingested orally or injected Can also be ingested orally or injected Easy to make in small clandestine laboratories Easy to make in small clandestine laboratories Prior to 1990’s was made using ephedrine Prior to 1990’s was made using ephedrine Pseudoephedrine became new ingredient Pseudoephedrine became new ingredient 38

39. 39

40. Crystal Meth 40

41. Crystal Meth: Pathophysiology Causes vasoconstriction as well as bronchodilation Causes vasoconstriction as well as bronchodilation May last up to 4 and 6 hours after a small ingested dose May last up to 4 and 6 hours after a small ingested dose Effect on the brain is due to norepinephrine and dopamine 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 High doses of amphetamine can cause palpitations and chest pain with a risk of myocardial infarction 41

42. Crystal Meth: Signs & Symptoms Dilated pupils Dilated pupils Dry mouth Dry mouth Euphoria Euphoria Decreased appetite Decreased appetite Rapid speech Rapid speech Irritability/Argument Irritability/Argument Depression Depression Nasal congestion Nasal congestion Insomnia Insomnia Weight loss Weight loss Increased HR, BP & Temperature Increased HR, BP & Temperature Restlessness Restlessness No interest in food or sleep. No interest in food or sleep. Violent Violent Paranoia Paranoia 42

43. Crystal Meth: Treatment Scene safety Scene safety Extra caution needed if there is suspected meth lab on scene 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 Highly explosive potential for years due to chemicals used and residue left behind in the environment Meth lab requires Haz-Mat response Meth lab requires Haz-Mat response ABC’s ABC’s IV, O 2, & EKG IV, O 2, & EKG Important to monitor EKG continuously due to potential cardiac issues Important to monitor EKG continuously due to potential cardiac issues 43

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 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 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. 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. 44

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. 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. 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. 45

46. Meth Lab Recognition EXCESSIVE OR UNUSUAL TRASH – Meth makers produce large quantities of unusual waste that may contain, for example: EXCESSIVE OR UNUSUAL TRASH – Meth makers produce large quantities of unusual waste that may contain, for example: packaging from cold tablets packaging from cold tablets lithium batteries that have been torn apart lithium batteries that have been torn apart used coffee filters with colored stains or powdery residue 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 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 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. plastic or rubber hoses, duct tape, rubber gloves, or respiratory masks. 46

47. Meth Labs – A Dangerous Place Typical products used Typical products used Explosive environments Explosive environments 47

48. Club/Rave/Party Drugs Very popular in universities, nightclubs, and party environments Very popular in universities, nightclubs, and party environments Ecstasy – MDMA Ecstasy – MDMA Modified form of methamphetamines Modified form of methamphetamines Rohypnol – Date rape drug, roofies Rohypnol – Date rape drug, roofies Strong benzodiazepine Strong benzodiazepine Often used for sexual purposes Often used for sexual purposes To stimulate and enhance the sexual experience To stimulate and enhance the sexual experience To sedate and cause amnesia to facilitate raping the victim To sedate and cause amnesia to facilitate raping the victim 48

49. Ecstasy/MDMA: Background Research in animals has shown damage to specific neurons in the brain Research in animals has shown damage to specific neurons in the brain Has stimulant and hallucinogenic properties Has stimulant and hallucinogenic properties Reduces inhibitions, eliminates anxiety and produces feeling of empathy for others Reduces inhibitions, eliminates anxiety and produces feeling of empathy for others Enables users to endure all night and sometimes 2-3 day parties Enables users to endure all night and sometimes 2-3 day parties Suppresses need to eat, drink, or sleep Suppresses need to eat, drink, or sleep Effects begin in 30 minutes; last 4 – 6 hours Effects begin in 30 minutes; last 4 – 6 hours 49

50. Ecstasy: Background Is taken orally – pill form with multiple logos Is taken orally – pill form with multiple logos May cause psychological addiction May cause psychological addiction Polydrug use often involved Polydrug use often involved Mix of a variety of chemicals simultaneously taken Mix of a variety of chemicals simultaneously taken Product only manufactured illegally Product only manufactured illegally Can be questionable regarding composition Can be questionable regarding composition There are no specific treatments for MDMA abuse and addiction There are no specific treatments for MDMA abuse and addiction In high doses can cause severe hyperthermia In high doses can cause severe hyperthermia 50

51. Ecstasy 51

52. Ecstasy: Signs & Symptoms Dilated pupils Dilated pupils Intense euphoria Intense euphoria Peacefulness Peacefulness Empathy/sympathy/acceptances Empathy/sympathy/acceptances Increased B/P, heart rate Increased B/P, heart rate Sweating Sweating Constant motion, excessive talking Constant motion, excessive talking Teeth clenching (use pacifiers or cigarettes) Teeth clenching (use pacifiers or cigarettes) Muscle spasms Muscle spasms 52

53. Ecstasy: Treatment Normal scene safety precautions Normal scene safety precautions ABC’s ABC’s IV, O 2, and EKG monitor IV, O 2, and EKG monitor Monitor temperature Monitor temperature 53

54. Rohypnol® Benzodiazepine smuggled into the USA Benzodiazepine smuggled into the USA Best known as “date rape” drug Best known as “date rape” drug Placed into alcoholic drink of unsuspecting victim Placed into alcoholic drink of unsuspecting victim Removes inhibitions, causes blackouts and memory loss when mixed with alcohol Removes inhibitions, causes blackouts and memory loss when mixed with alcohol Victim incapacitated; has soothing effect Victim incapacitated; has soothing effect Amnesic to the events Amnesic to the events Long-lasting Long-lasting 10 times more powerful than Valium® 10 times more powerful than Valium® 54

55. Synthesized Marijuana Labeled “not for human consumption” Labeled “not for human consumption” But is regularly smoked But is regularly smoked Produces a marijuana type high at low doses Produces a marijuana type high at low doses Can’t guarantee dosage in the different brands Can’t guarantee dosage in the different brands Popular to use because not traceable in drug tests Popular to use because not traceable in drug tests Can increase heart rate, B/P, seizure activity, hallucinations, and paranoia Can increase heart rate, B/P, seizure activity, hallucinations, and paranoia 55

56. Supplemental Oxygen Delivered to patients when: Delivered to patients when: Hypoxemia is evident with oxygen saturation <94% Hypoxemia is evident with oxygen saturation <94% Signs of respiratory distress are evident Signs of respiratory distress are evident Capnography is most accurate method to measure exhaled carbon dioxide (CO 2 ) levels Capnography is most accurate method to measure exhaled carbon dioxide (CO 2 ) levels Evaluates effectiveness of ventilations Evaluates effectiveness of ventilations Evaluates effectiveness of CPR Evaluates effectiveness of CPR Can determine return of spontaneous circulation (ROSC) during CPR Can determine return of spontaneous circulation (ROSC) during CPR 56