Download Mod II - Illicit Drug Emergencies

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
1
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.
2
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.
3
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.
4
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
5
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
6
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
7
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
8
Poison Control Center
240per day/7 days per week
9
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
10
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
11
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
12
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
13
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
14
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
15
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).
16
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
17
Heroin
18
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
19
Black Tar Heroin
20
Treatment of Heroin
• Environmental 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
21
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
22
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
23
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
24
Heroin…
• http://youtu.be/Hj6NvwDLjAE
• http://youtu.be/6mSq69FT3jM
25
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)
26
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
27
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
28
Cocaine
29
Crack Cocaine
30
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
31
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
32
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
33
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!
34
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
35
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
36
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
37
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
38
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
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
40
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
41
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
42
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
44
Crystal Meth
45
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
46
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
47
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
48
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.
49
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.
50
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.
51
Meth Labs – A Dangerous Place
• Typical products used
• Explosive
environments
52
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
53
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
54
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
55
Ecstasy
56
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
57
Ecstasy: Treatment
•
•
•
•
Normal scene safety precautions
ABC’s
IV, O2, and EKG monitor
Monitor temperature
58
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®
59
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
60
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
61
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
62
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
63
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?
64
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
65
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
66
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
67
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
68
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
69
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
70
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
71
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.
72
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
73
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
74
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
75
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
76
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
77
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
78
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?
79
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
80
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
81
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
82
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
83
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?
84
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
85
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
86
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?
87
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
88
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)
89
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?
90
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
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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
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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
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Case Scenario #4
Impression of 12 lead EKG?
Inferior wall MI – ST elevation II, III, aVF
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Case Scenario #4
• EMS treatment for this patient now?
– 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
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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
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Bibliography
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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
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