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Street Drug OD

Street Drug OD. Nathanael Wood, MD May 9, 2006. Street Drug Overdoses. Overdoses in General Rock Smack XTC PCP. What is an Overdose?. Not based on dose. Based on Clinical Picture An “Overdose” is any clinically relevant instability from drug ingestion. .

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Street Drug OD

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  1. Street Drug OD Nathanael Wood, MD May 9, 2006

  2. Street Drug Overdoses • Overdoses in General • Rock • Smack • XTC • PCP

  3. What is an Overdose? • Not based on dose. • Based on Clinical Picture • An “Overdose” is any clinically relevant instability from drug ingestion.

  4. Recreational Drugs Popular in the Capital Region Most common in the Emergency Department: • Alcohol • Cocaine and Crack • Heroin and Opioids • Marijuana

  5. Case Study • 24 year old female found seizing. • No medical problems • Vitals: HR 153, BP 205/122, O2 sat 85%, RR 22 • Continues to seize after valium

  6. Cocaine

  7. Cocaine • Andes, Mexico, West Indies, and Indonesia. • Erythroxylon coca • Diminish fatigue at altitude.

  8. Cocaine • Sigmund Freud • 1884: “Über Coca” • “Wonder drug” • Depression • Alcohol dependence Freud became severely addicted.

  9. Cocaine • Most popular street drug • Water-soluble HCl salt • IV • Snorted • Also SC or IM • Slow absorption • Less “rush”

  10. Crack • How to make Crack • Cocaine • Baking soda and water • Boil • Separate • Late 1980s • Smoke vapors • Popping sound • “Rock”

  11. Cocaine: Pathophysiology • CNS Stimulant • Blocks reuptake of norepinephrine and dopamine.

  12. Cocaine: Pathophysiology • Norepenepherine • Sympathetic stimulation • “Fight or Flight” • Pupil dilation • Elevated blood pressure • Tachycardia • Hyperglycemia • Hyperthermia • Cardiac arrhythmias • Seizures

  13. Cocaine: Pathophysiology • Dopamine • Pleasure response • Euphoria • Addiction

  14. Assessment • ABC • If decreased mental status: • Narcan • Finger stick glucose or D50

  15. Cocaine Overdose • Convulsions • Stroke • Chest Pain • Hyperthermia • Hypertension

  16. Convulsions Any route Dose dependent Usually benign Cocaine Overdose • Can be caused by more serious complications like stroke or intracranial hemorrhage.

  17. Convulsions ABC Benzodiazepines Valium Midazolam Avoid restraints* Cocaine Overdose

  18. Cocaine Overdose • Stroke • Bleed or Ischemia • Seconds to 12 hrs

  19. Cocaine Overdose • Stroke • ABC • Rapid transport • Neurosurgery

  20. Cocaine Overdose • Chest Pain • Vasoconstriction • Cardiac ischemia • Angina • MI

  21. Cocaine Chest Pain • Treat them as real • O2, aspirin, nitrates, EKG • NO BETA-BLOCKERS • NO LOPRESSOR (metoprolol) • Benzodiazepines

  22. Cocaine Overdose • Hyperthermia • 114° F • Deadly • Avoid coverings • Avoid restraints • Cooling can be life-saving Treat shivering and psychomotor agitation with benzodiazepines to reduce heat production.

  23. Cocaine Overdose • Hypertension • Alpha-mediated vasoconstriction • DO NOT USE BETA-BLOCKERS • Unopposed alpha stimulation • WORSENS HYPERTENSION! • Use Benzodiazepines • Consider Nitro with medical direction.

  24. Cocaine Overdose • Body Packers • Mules • Transport drugs • Ingested packages • International flights • Well contained packages Breakage of packages can cause severe OD.

  25. Cocaine Overdose • Body stuffers • Ingest drugs they have on them • Concealment • Packages not well made • Rupture easily • Can cause severe overdoses Be suspicious of symptomatic patients in police custody.

  26. Cocaine Overdose • Packers and Stuffers • Treat as OD • ER: bowel decontamination • Surgery

  27. Cocaine Overdose - Overview • ABC • O2, IV, cardiac monitor • Detailed history: • What and how much • Co-ingestions • Fingerstick • Narcan • NO BETA BLOCKERS • Treat chest pain like it’s real • NO BETA BLOCKERS

  28. Cocaine Overdose - Overview • Cooling • Avoid restraints if possible • Use Benzodiazepines • Agitation • Seizure • Hypertension • Shivering when hyperthermic

  29. Heroin

  30. Heroin • Semisynthetic • Derived from morphine • Opiates / Narcotics family • Opium • Methadone • Hydrocodone • Oxycontin

  31. Heroin • 1874 • Safer, non-addictive substitute to morphine • 1920: Dangerous Drugs Act • Drove it underground • Most frequently abused narcotic in US • Followed by codeine and methadone

  32. Heroin • Pure form • White powder • Bitter taste • Street form • Frequently mixed / cut • Maximize profits • Variety of colors • White to dark brown

  33. Heroin • Impure heroin • Slower absorption • Limits rush when sniffed or snorted • IV injection

  34. 100-mg bag in 1980 3.6% pure $3.90 100-mg bag in 1999 38.2% pure $0.80 Heroin South American samples have highest purity, reaching the 90% range. Snorting and smoking are slowly becoming the methods of choice and are especially by the younger users.

  35. Heroin Pathophysiology • CNS effects • Analgesia • Sedation • Euphoria • Respiratory depression

  36. Heroin Pathophysiology • CNS effects • Pupil constriction • Nausea / Vomiting • Cough suppression • Physical dependence

  37. Heroin Pathophysiology • Peripheral effects • Histamine release • Bradycardia • Constipation

  38. Heroin Pathophysiology • Antidote • Narcan

  39. IV use: Onset: 1 minute Rush: few minutes Sedation: 1 hour Half life: 15 to 30 min Heroin

  40. IM / SC / snorted: Not common Slower onset Less rush Heroin

  41. Heroin Overdose • Fatal overdoses • Respiratory depression • Co-ingestion • Alcohol • Cocaine • Antidepressants

  42. Heroin Overdose • Nonfatal complications • Pulmonary edema • Up to 24 hrs after use • Prolonged coma • Rhabdomyolisis • Compartment syndrome

  43. Should be easy to recognize 1. Coma 2. Respiratory depression or apnea 3. Pupil constriction Heroin Overdose

  44. Can be mimicked Stroke ICH (pontine hemorrhage) Hypoglycemia Hypoxia Heroin Overdose

  45. Heroin Overdose • Clinical picture can be confused • Co-ingestions • Adulterants • Preexisting medical conditions

  46. Heroin Overdose • Injection of a highly concentrated sample by an unsuspecting client • Suicide attempt • Co-ingestion As with cocaine, can have body stuffers and body packers, leading to severe overdoses.

  47. Heroin Overdose - Overview • ABC’s • O2, IV, cardiac monitor • Detailed history • What and how much • Co-ingestions • Consider impurities • Fingerstick • Narcan

  48. Cocaine Sympathetic response “Fight or Flight” “Upper” Dilated pupils Agitation Tachycardia Hypertension Heroin Parasympathetic response “Feed or Breed” “Downer” Constricted pupils Sedation Bradycardia Respiratory depression Cocaine vs. Heroin

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