Illicit Drug Emergencies

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 Center240per day/7 days per week 1-800-222-1222

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, O2, & 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… http://youtu.be/Hj6NvwDLjAE http://youtu.be/6mSq69FT3jM

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 O2 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

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, O2, & 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