Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Nate Wood - Adirondack Area Network
Document related concepts
Pharmacogenomics wikipedia , lookup
Psychedelic therapy wikipedia , lookup
Prescription costs wikipedia , lookup
Effects of long-term benzodiazepine use wikipedia , lookup
Pharmaceutical industry wikipedia , lookup
Drug interaction wikipedia , lookup
Serotonin syndrome wikipedia , lookup
Neuropharmacology wikipedia , lookup
Dextropropoxyphene wikipedia , lookup
Urban legends about drugs wikipedia , lookup
Transcript
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. Recreational Drugs Popular in the Capital Region Most common in the Emergency Department: • Alcohol • Cocaine and Crack • Heroin and Opioids • Marijuana 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 Cocaine • Andes, Mexico, West Indies, and Indonesia. • Erythroxylon coca • Diminish fatigue at altitude. Cocaine • Sigmund Freud • 1884: “Über Coca” • “Wonder drug” • Depression • Alcohol dependence Freud became severely addicted. Cocaine • Most popular street drug • Water-soluble HCl salt – IV – Snorted • Also SC or IM – Slow absorption – Less “rush” Crack • How to make Crack – Cocaine – Baking soda and water – Boil – Separate • Late 1980s • Smoke vapors • Popping sound • “Rock” Cocaine: Pathophysiology • CNS Stimulant • Blocks reuptake of norepinephrine and dopamine. Cocaine: Pathophysiology • Norepenepherine • Sympathetic stimulation • “Fight or Flight” – Pupil dilation – Elevated blood pressure – Tachycardia – Hyperglycemia – Hyperthermia – Cardiac arrhythmias – Seizures Cocaine: Pathophysiology • Dopamine – Pleasure response – Euphoria – Addiction Assessment • ABC • If decreased mental status: – Narcan – Finger stick glucose or D50 Cocaine Overdose • Convulsions • Stroke • Chest Pain • Hyperthermia • Hypertension Cocaine Overdose • Convulsions – Any route – Dose dependent – Usually benign Can be caused by more serious complications like stroke or intracranial hemorrhage. Cocaine Overdose • Convulsions – ABC – Benzodiazepines • Valium • Midazolam – Avoid restraints* Cocaine Overdose • Stroke – Bleed or Ischemia – Seconds to 12 hrs Cocaine Overdose • Stroke – ABC – Rapid transport – Neurosurgery Cocaine Overdose • Chest Pain – Vasoconstriction – Cardiac ischemia – Angina – MI Cocaine Chest Pain • Treat them as real – O2, aspirin, nitrates, EKG – NO BETA-BLOCKERS • NO LOPRESSOR (metoprolol) – Benzodiazepines 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. Cocaine Overdose • Hypertension – Alpha-mediated vasoconstriction – DO NOT USE BETA-BLOCKERS • Unopposed alpha stimulation • WORSENS HYPERTENSION! – Use Benzodiazepines – Consider Nitro with medical direction. Cocaine Overdose • Body Packers – Mules – Transport drugs – Ingested packages – International flights – Well contained packages Breakage of packages can cause severe OD. 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. Cocaine Overdose • Packers and Stuffers – Treat as OD – ER: bowel decontamination – Surgery 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 Cocaine Overdose - Overview • Cooling • Avoid restraints if possible • Use Benzodiazepines – Agitation – Seizure – Hypertension – Shivering when hyperthermic Heroin • Semisynthetic • Derived from morphine • Opiates / Narcotics family – Opium – Methadone – Hydrocodone – Oxycontin 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 Heroin • Pure form – White powder – Bitter taste • Street form – – – – Frequently mixed / cut Maximize profits Variety of colors White to dark brown Heroin • Impure heroin – Slower absorption – Limits rush when sniffed or snorted • IV injection Heroin • 100-mg bag in 1980 • 100-mg bag in 1999 – 3.6% pure – 38.2% pure – $3.90 – $0.80 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. Heroin Pathophysiology • CNS effects – Analgesia – Sedation – Euphoria – Respiratory depression Heroin Pathophysiology • CNS effects – Pupil constriction – Nausea / Vomiting – Cough suppression – Physical dependence Heroin Pathophysiology • Peripheral effects – Histamine release – Bradycardia – Constipation Heroin Pathophysiology • Antidote – Narcan Heroin • IV use: – Onset: 1 minute – Rush: few minutes – Sedation: 1 hour – Half life: 15 to 30 min Heroin • IM / SC / snorted: – Not common – Slower onset – Less rush Heroin Overdose • Fatal overdoses – Respiratory depression – Co-ingestion • Alcohol • Cocaine • Antidepressants Heroin Overdose • Nonfatal complications – Pulmonary edema • Up to 24 hrs after use – Prolonged coma • Rhabdomyolisis • Compartment syndrome Heroin Overdose • Should be easy to recognize 1. Coma 2. Respiratory depression or apnea 3. Pupil constriction Heroin Overdose • Can be mimicked – Stroke – ICH (pontine hemorrhage) – Hypoglycemia – Hypoxia Heroin Overdose • Clinical picture can be confused – Co-ingestions – Adulterants – Preexisting medical conditions 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. Heroin Overdose - Overview • ABC’s • O2, IV, cardiac monitor • Detailed history – What and how much – Co-ingestions – Consider impurities • Fingerstick • Narcan Cocaine vs. Heroin Cocaine Heroin • Sympathetic response • Parasympathetic response • “Fight or Flight” • “Feed or Breed” • “Upper” • “Downer” – Dilated pupils – Constricted pupils – Agitation – Sedation – Tachycardia – Bradycardia – Hypertension – Respiratory depression 3,4-methylenedioxymethamphetamine • MDMA • E • Ecstasy • X • XTC • Clarity • Adam • Stacy MDMA • Amphetamine derivative • 1914: synthesized by Merck and Company • 1950’s: US military – possible brainwashing agent • 1970’s: Psychiatry – psychotherapy – marital counseling MDMA • 1980’s: Recreational use spread – Raves – Major cities, US and Europe MDMA - Effects • Hallucinogenic amphetamine • Amphetamine (speed) + LSD (acid) – Empathy – Euphoria – Disinhibition – Increased sensuality MDMA • Forms – – – – Capsule Powder Liquid Tablets • • • • • Doves Blue elephants 8½ Bugs Bunny Ferraris MDMA • Long acting – Duration of action: 8-24 hrs – Half-life:12-34 hrs. • Metabolized in the liver and excreted renally. • Small subset of the population is missing the liver enzyme that metabolizes MDMA – Can be fatal MDMA • One tablet – 50-100 mg – $20-25. • Initial effects occur in 30-60 minutes. • Peak effects occur at 90 min – May persist 4-8 hrs. • Tolerance develops rapidly MDMA • Often impure • Substances mixed with MDMA – Heroin – Ketamine – Ephedrine (herbal ecstasy). MDMA - Effects • Initial 30 minutes – – – – – – – – Anxiety Tachycardia Elevated BP Diaphoresis Jaw clenching Paresthesias Dry mouth Increased psychomotor activity – Blurred vision • Within 1 hour – – – – – Relaxation Euphoria Empathy Increased communication. Increased sensory tactile enhancement – Mild visual distortions, such as halos. MDMA - Effects • If too much MDMA is consumed in a single session, – Restlessness – Paranoia – Anxiety • Following the acute effects of MDMA, “Blues.” – 24- to 48-hrs – Lethargy – Anorexia – Dysphoria. – Users often co-ingest to help ease the “Blues" MDMA - Toxicity • “Seratonin Syndrome” – Exacerbated by dancing in hot clubs – Hyperthermia – Dehydration – Muscle breakdown – Liver toxicity – Renal Failure MDMA - Toxicity • Hyponatremia – Hyperthermia – Seratonin syndrome, – Increased water intake – Excessive sweating with physical exertion • Altered mental status • Seizure • Coma MDMA - Toxicity • Cardiovascular – Hypertension – Dysrhythmias • Stroke and Intracranial bleeds – Rare MDMA - Overview • ABC’s. • Prehospital care is supportive. • IV, O2, Frequent vital sign check, fingerstick glucose. • Most frequent morbidity/mortality is from hyperthermia and electrolyte abnormalities. • Consider benzo’s for anxiety, agitation, panic reactions, and seizures. Phencyclidine • PCP • Angle Dust PCP • 1950’s: Developed for use as a general anesthetic for surgery. • 1965: Discontinued because of side effects of psychotic features, dysphoria, and extreme agitation. • 1960’s: Maufactured illegally. • 1970’s: Popular street drug. PCP • White crystalline powder available in liquid, tablet, or powder forms. • It can be snorted, ingested orally, injected, or smoked. PCP • Dissociative anesthetic. • Effects occur in minutes. • Lasts several hours. • May last up to 48 hrs with overdose. PCP - Effects • Nystagmus (horizontal, vertical, or rotary). • Hypertension. • Acute brain syndrome involving confusion, amnesia, disorientation, and violence. • Agitation and violent behavior. • Tachycardia. • Bizarre behavior including public nudity. • Hallucinations and delusions. • Miosis - Often reported with a blank stare PCP - Rare Effects – Seizures – Dystonia – Ataxia – Apnea (often seen with co-ingestants) – Catatonia – Coma – Hypertensive crisis – Intracranial and subarachnoid hemorrhage PCP – Prehospital Care • ABC’s • Supportive care. • Fingerstick glucose. • Physical restraints may be required to prevent selfinjury and to protect the medical staff. • Narcan for depressed mental status (for possible co-ingestion) • Benzo’s for severe agitation.
