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Substance Abuse Ray Taylor Valencia Community College Department of Emergency Medical Services Notice All rights reserved. Slide show used with permission only for the purposes of educating emergency medical providers (EMTs and Paramedics) No portion of this presentation may be reproduced, stored in a retrieval system in any form or by any means (including but not limited to electronic, mechanical, photocopying etc.) without prior written permission from the author Objectives Approach to the overdose patient Recognize toxic syndromes Discuss common drugs of abuse Recognize patterns of substance abuse Discuss Alcohol Abuse Drug Abuse Refers to the use of prescription drugs for nonprescribed medical use Emergencies resulting from drug abuse • Adverse effects caused by the drug or impurities mixed with drugs • Life threatening infections from IV or intradermal injection • Accidents during intoxication • Drug dependence or withdrawal syndrome Background 2.4 to 4 million per year Accidental vs. Suicidal Over half are children 1-5 • Only5% of fatalities Conservatively estimated that 45 million Americans use drugs in a reactional way Adults: chemical exposure vs. suicidal Approach to the Overdose patient ABC’s Coma cocktail • narcan, D50 • thiamine Assessment: history and physical Monitoring Unbiased approach Approach to the Overdose Patient Gut Decontamination Ipecac Gastric Lavage Activated Charcoal Whole Bowel Irrigation Dialysis Ipecac Should not be administered routinely Highly variable Effectiveness decreases with time Administration in the ED should be abandoned Delays charcoal, antidotes, and whole bowel irrigation Why Talk About It Then Can mask signs of toxicity Most useful when unknown or toxic amount of substance AND Not close to the ED Within 60 minutes (solids) Within 30 minutes (liquids) Dose: 6 to 12 months: • 5 to 10 cc (with water) 1 to 12 years: • 15 cc (with water) 12 years and older: • 15 to 30 cc (with water) Ipecac/Family Guy Gastric Lavage Lavage is rarely recommended Gastric aspiration 30 minutes post ingestion < 40% removed Activated Charcoal Not routinely administered Will be used most often within 1 hour post ingestion No data to support or exclude its use Recommended dose of 1g/kg Don’t need sorbitol • Makes “shit” come out faster Whole Bowel Irrigation Should not be administered routinely Toxic ingestions of SR or EC drugs Body packers Stuffers Start within 4 hours Polyethylene glycol electrolyte solution N/G tube needed Whole Bowel Irrigation Adults: • 1000 cc/hr and increase to 2000cc/hr Children ( 9 months and up): • 250 cc/hr and increase to 500 cc/hr Until rectal effluent is clear May give AC prior Do not give MDC during. MDC after WBI Toxins Toxidromes • Similar toxins typically have similar signs and symptoms. • In some cases it may be difficult to identify a specific toxin. Toxic Syndromes (1 of 5) Toxic Syndromes (2 of 5) Toxic Syndromes (3 of 5) Toxic Syndromes (4 of 5) Toxic Syndromes (5 of 5) Toxic Syndromes Anticholinergic • dry as a bone…. Sympathomimetic Opiate/ Sedative Cholinergic • SLUDGE Serotonin Drug Abuse DSM IV criteria: • Maladaptive pattern of substance use leading to impairment manifested by: • recurrent use resulting to fulfill obligations • recurrent use in a way that is physically hazardous • recurrent legal problems related to usage • continued use despite persistent social or interpersonal problems Substance Abuse and Overdose Addiction • • • • Habituation Physiological dependence Psychological dependence Tolerance Withdrawal Drug Overdose Common Drugs of Abuse Narcotics CNS Depressants CNS Stimulants Hallucinogens Drugs of Abuse Common Drugs of Abuse (1 of 4) Common Drugs of Abuse (2 of 4) Common Drugs of Abuse (3 of 4) Common Drugs of Abuse (4 of 4) Narcotics Heroin accounts for approximately 90% of the narcotic abuse in U.S. Pure heroin is a bitter-tasting white powder that is usually adulterated (cut) • • • • Lactose Sucrose Backing soda Starch Narcotics A typical “bag” is the single dose unit of heroin and may weigh 100mg, which on average is only 5% pure Other narcotics include: • Morphine, methadone, meperidine, codeine, oxycodone, propoxyphene • Designer opiates: alpha fentanyl (China White) Narcotics Depending on the narcotic preparation, these drugs may be • Taken orally • Injected intradermally (skin popping) • Injected intravenously (mainlining) • Taken intranasally (snorted) • Smoked Narcotic CNS depression, drowsiness, euphoria, miosis?, slow RR, N,V W/D symptoms- not life threatening Other considerations: infection, abscess, NCPE, epidural abscess, embolization, Lomotil Treatment: Naloxone 2mg IV or IM to an 8mg total CNS Depressants Sedatives/Hypnotic agents Include benzodiazepines and barbiturates Usually taken orally, but may be diluted and injected intravenously Use with alcohol increases their effects CNS Depressants Benzodiazepines are among the best known and most widely prescribed drugs to control anxiety, stress, and insomnia Work by depressing brain function and are often abused for their sedative effects Benzodiazepines Stimulate Gamma-aminobutyric acid (GABA) receptors GABA receptors are predominant inhibitory neuroreceptors in CNS Stimulation produces sedative effects • Alters synaptic transmission in spinal cord leading to skeletal muscle relaxation Benzodiazepines Relatively nontoxic, but may accentuate the effects of other sedative-hypnotic agents Common benzodiazepines • • • • Valium Librium Versed Klonipin Barbiturates General CNS depressants that inhibit impulse conduction in the ascending reticular activating system • Once widely prescribed, but have been replaced by benzodiazepines • Commonly prescribed barbiturates • Phenobarbitol • Amobarbitol • Secobarbital CNS Depressant Benzos, Barbituates, GABA agonists in the CNS Coma, resp depression, CV depression W/D: restlessness, irritable, seizures BZD are safer GHB, Rohybnol, Treatment: Supportive, Flumazenil CNS Stimulants Amphetamines are drugs frequently used to produce general mood elevation, improve task performance, suppress appetite, and prevent sleepiness CNS Stimulants Structurally, amphetamines are similar to endogenous catecholamines, but differ in their pronounced effects on the CNS Adverse effects include: • • • • • • Tachycardia Increased BP Tachypnea Agitation Dilated pupils Tremors, disorganized behavior CNS Stimulants Severe cases, patients may exhibit psychosis and paranoia, and experience hallucinations Sudden withdrawl of amphetamine use may result in “crash” stage • Patients become depressed, suicidal, incoherent or comatose CNS Stimulants Amphetamines, cocaine, PCP Symptoms: euphoria, stimulant, delirium, SZ, ICH, MI, CVA The Scope of Cocaine Cocaine One of the most popular illegal drugs in U.S. 4 million Americans use drug regularly Cocaine related deaths are third leading cause of drug-related fatalities, proceeded only by heroin and drug-alcohol combinations Cocaine Most commonly used as a fine white powder crystalline powder • Street forms are usually adulterated and vary in purity from 25%-90% • Doses vary from near 0 to 200mg • Usually inhaled intranasally by snorting a “line” containing 10-35mg of the drug Cocaine After absorption through the mucus membranes, effects begin within minutes Peak effects occur in 15-60 minutes after use Half life of 1-2.5 hours Cocaine Parenteral administration • SQ, IV, IM routes • IV route provides immediate absorption and intense stimulation • Peak occurs within 5 minutes and a half life within 50 minutes Cocaine Feebase or “crack” cocaine • More potent formulation prepared by mixing powdered street cocaine with an alkaline solution and then adding a solvent such as ether • Combination separates into 2 layers with top layer containing the dissolved cocaine • Evaporation of solvent results in pure cocaine crystals which are smoked and absorbed via lungs Cocaine Cocaine in its crystallized form is called “rock” or “crack” Popping sound produced when the crystals are heated Freebase is often combined with marijuana or tobacco and smoked in a water pipe Equal to IV use in intensity and pleasure Cocaine Blocks reuptake of NE Use *benzodiazepine (diazepam 5-20 mg) Lidocaine (also a sodium channel blocker like cocaine) – competes with cocaine at the sodium channel; risk of seizure due to synergistic toxic effect of Lidocaine in presence of cocaine Bicarb early if coded Cocaine Major CNS stimulation that causes profound sympathetic discharge Increased circulating levels of catecholamines result in excitement, euphoria, talkitiveness, and agitation Cocaine Effects of cocaine can precipitate cardiovascular and neurological complications • • • • • • Cardiac dysrhythmias MI Seizures Strokes (intracranial hemorrhage) Hyperthermia Psychiatric disorders Cocaine Can occur with any form of the drug and route of administration Adult fatal dose is thought to be about 1200mg Fatalities from cocaine induced cardiac dysrhythmias have been reported with a single dose of 25-30mg Cocaine Treatment • Airway and ventilation • Oxygen administration and monitor saturation • Cardiac monitoring • Treat dysrhythmias • Beta blockade • IV NS • Control and treat seizures • Sympathomimetic toxidrome (hypertension, tachycardia, agitation) Valium/Versed Phencyclidine Overdose A dissociative analgesic with sympathomimetic and CNS stimulant and depressant properties PCP illegally sold in tablet or powder form to be taken orally, intranasally or with other drugs to be smoked PCP Most tablets contain about 5mg PCP As a rule, PCP in powder from is relatively pure (50-100%) Chronic use results in permanent memory impairment and loss of higher brain functions PCP Low dose toxicity (less than 10mg) • Produces an unpredictable state of drunkeness, euphoria, confusion, disorientation, agitation, or sudden rage • Intoxicated patient often has blank stare, stumbling gait, and is dissociative PCP Low dose toxicity is best managed by keeping sinsory stimulation to a minimum Violent and combative patients require protection from self-injury Closely monitor vital signs Increasing motor activity and muscle rigidity of often precedes seizures PCP High dose toxicity (More than 10mg) • • • • • • Respiratory depression Hypertensive crisis Tachycardia Coma PCP psychosis Treatment ECSTASY Methamphetamine Lab Names XTC E X LOVER’S SPEED CLARITY ADAM What is Ecstasy? 3,4-Methylenedioxymethamphetamine “MDMA” What does it look like? MDMA ???? PMA or PMMA Amphetamine LSD 2-CB Aspirin Ketamine Atropine 4-MTA DXM Caffeine How does it work? Responds by releasing Serotonin, Dopamine and Norepinephrine. How much does one take? Standard oral dose is 80 – 150 mg • Most good quality pills contain generally 80-120mg Once the “sweet spot” is obtained, a higher dosage is not necessarily more desirable Lethal dose 106mg/kg or 6000 mg Onset and Duration Onset 30 – 60 minutes • Coming up 5-20min. • Plateau 2-3 hours • Coming down 1-2 hours • Duration 3-4 hours • After affects 3-24 hours Positive Effects Extreme mood lift Increased willingness to communicate Increased energy Ego softening Feeling of love, comfort & empathy Increased appreciation of music Profound lifechanging spiritual experience Urge to hug & kiss Neurotically based fear dissolution Neutral Effects Visual distortion Pupil dilation Appetite loss Nystagmus Restlessness, nervousness Change in body temp regulation Negative Effects Increased HR & B/P Hyperthermia Dehydration Hyponatremia Nausea & vomiting Headache, dizziness Jaw clenching, tongue & cheek chewing Post-trip CRASH Depression Hangover Inappropriate &/or unintended emotional bonding Say inappropriate things Muscle tension Long-Term Effects Psychological difficulties - ? permanent brain damage - confusion - memory loss - depression - sleep disorders - drug craving - severe anxiety - paranoia Treatment and Care Treatment is related to symptoms - Tachycardia - Hypertension - Hyperthermia - Dehydration - Hyponatremia Hallucinogen 15 million Americans PCP: nystagmus, agitation-sz coma LSD: paranoia, anxiety-flashbacks Peyote (Mescaline): N/V, diaphoresis, anxiety Causes sensory experiences outside the mind Marijuana: Euphoria, relaxation Mushrooms: N/V Hallucinogens Substances that cause perceptual distortions Most common hallucinogens are PCP and lysergic acid diethylamide (LSD) GHB Gamma-Hydroxybutyrate Grievous Bodily Harm; Georgia Home Boy; Liquid Ecstasy; Liquid X; Liquid E; Liquid G; G-Riffick; Organic Quaalude; Somatomax; Scoop; Easy Lay; Fire Water and Blue Nitro, Invigorate or Longevity Naturally occurring component of metabolism, highest levels found in basal ganglia & hypothalamus, but also in major organs GHB Synthesized in 1960s – thought to be beneficial Crosses blood-brain barrier turning into GABA Stimulates Growth Hormone release aiding in fat reduction & body building Now popular among recreational users & violent criminals “Date Rape” drug & deadly when mixed with ETOH GHB GHB ingested, 20-30 mins to brain and binds with GABA-B receptors inhibiting noradrenaline release in hypothalamus & mediating release of an opiate-like substance in the striatum GHB also produces a biphasic dopamine response, increasing the release of dopamine at high GHB concentrations & inhibiting its release at lower doses GHB CNS depression (10 mg/kg = short-term amnesia & hypotonia; 20-30 mg/kg = drowsiness & sleep; 50-70 mg/kg = hypnosis, then continue to deep coma) and seizure activity Narcan, Charcoal, Atropine for bradycardia, Physostigmine for coma Tricyclic Antidepressants TCAs are commonly prescribed in the treatment of depression • Drugs work by blocking the uptake of norepinephrine, serotonin, or both into the presynaptic neuron • Alters sensitivity of brain tissue to actions of these chemicals • Tetracyclic Antidepressants TCAs TCA toxicity is thought to result from central and peripheral atropine like anticholinergic effects and direct effects on myocardial functions Commonly prescribed TCAs • Amitriptyline – elavil, endep, etrafon, vanatrip, levatate TCAs Commonly prescribed TCAs • • • • Clomipramine – anafranil Doxepin – sinequan, zonalon, triadapin Imipramine – trofinal, impril Nortriptyline – aventyl, pamelor, norventyl • Desipramine - norpramin • Protriptyline – vivactil • Trimipramine - surmontil TCAs Symptoms of overdose • Early • Dry mouth, blurred vision, confusion, inability to concentrate, and occasionally visual hallucinations TCAs Severe symptoms • Hypotension • Anticholinergic effects • Tachycardia, altered mental status • Miadriasis • AV conduction blocks • Prolonged QT interval • Wide QRS, VT, VF • Seizures • Coma • Death TCAs Treatment • • • • Airway and ventilation support Oximetric monitoring Cardiac monitoring/BP Alkalinization (Sodium Bicarbonate), anticonvulsants, physotigimine when appropriate • Magnesium for torsades Salicylates Widely available in prescription and over-the-counter • Acetylasalicylic acid (aspirin) • Cold preparations (oil of wintergreen) methyl salicylates • Combination with other analgesics • Oxycodone, propoxphene Salicylates Mechanism • Complex and includes interference with cellular glucose uptake and inhibition of enzymes that effect energy production, amino acid metabolism and acid buffering in the body. • Complications result from chronic and acute ingestions Salicylates CNS stimulation • Salicylates initially produce direct stimulation of the respiratory center causing and increase in rate and depth • This early respiratory alkalosis is followed by a compensatory elimination of bicarbonate ions by the kidneys and subsequent compensatory metabloic acidosis Salicylates CNS stimulation • After this period, there is an accumulation of intermediate acids involved in energy metabolism resulting in profound metabolic acidosis Salicylates GI irritation Glucose metabolism • Interference with cellular glucose uptake causes accumulation of serum glucose followed by its loss Fluid and electrolyte imbalance Neurological dysfunction Salicylates Coagulation effects • Alter normal platelet fuction Treatment • • • • • ABCs, oxygen Cardiac monitoring IV NS – large amounts Activated charcoal Possible IV glucose and sodium bicarbonate Acetaminophen Commonly prescribed analgesic and antipyretic agent available in both prescription and nonprescription preparations • Due to its widespread availability, there is a high incidence of accidental and intentional poisionings Acetaminophen Hepatic toxicity • Formation of hepatotoxic intermediate if not managed within 16-24 hours post ingestion • 30 standard size (325mg) tablets are toxic in the average adult • Causes hepatic necrosis Acetaminophen Toxic effects of acute ingestion • Doses of (140mg/kg or greater) can be classified in 4 stages • Mild symptoms – often masked by other ingested agents • Moderate – Nausea, vomiting, abdominal pain, weakness, fatigue, elevated liver enzymes Acetaminophen Toxic effects of acute ingestion • Severe – Liver function disruption • Critical – Liver failure • Antidotal therapy begun with 1624 hours complete recovery should occur Acetaminophen Emergency care • Respiratory, cardiac, and hemodynamic support • Ingestion <4 hours gastric decontamination • Definitive care • In-hospital administration of Nacetylcysteine (Mucomyst) Iron Forms of Iron Stages of toxicity Decontamination Treatment Iron Overdose Approximately 10% of ingested iron (mainly ferrous sulfate) is absorbed each day by the small intestines • After absorption, iron is converted and stored in iron storage protein and transported to liver, spleen, and bone marrow for incorporation into hemoglobin Iron Overdose Ingested iron exceeds the body’s ability to store it, the free iron circulates in blood and is deposited into other tissues Over ingestion of iron is corrosive to GI tract mucosa and may produce bloody vomitus, diarrhea, and dark stools Prehospital Treatment: Supportive Organophosphates Organophosphates Organophospates are very common and can be absorbed readily thru dermis Cause over stimulation and disrupts transmissions in the central and peripheral nervous systems • acetylcholine (neurotransmitter substance) • acetylcholinesterase (enzyme) blocked hyperactivity ensues SLUDGE • Salivation • Lacrimation • Urination • Defecation • GI cramping • Emesis • Miosis (pinpoint pupils) and muscle fasciculation Treatment • Protect yourself • Surface Decontamination • ABC’s • Aggressive airway management, suctioning and PPV • Warn the ED, complete decontamination Treatment • Drug Administration •Atropine (2mg every 5-15 min. in adults and .05 mg/kg in Peds) •Dries secretions, increases HR •Diazepam/Lorazepam if seizures are present Monitoring • ECG monitoring (may see all types of dysrhythmias) • GI decontamination followed by activated charcoal if ingested • Transport immediately • Surface decontamination is essential early in the evaluation and management (Warn the hospital) Alcoholism Major US problem High comorbidity Metabolism Medical consequences Alcoholic Emergencies Disulfiram reaction ETOH Most common substance of abuse in US Over 10 million in US; 200,000 die annually Involved in 1/2 of MVC fatalities, most homicides and 1/3 suicides 1/5 total national expenditure for hospital care Alcoholism Causes – 3 factors interact • Personality • Environment • Addictive nature of drug Also thought genetic and hormonal factors play a significant part Anyone can become dependent with ETOH consumption for long periods Alcohol Metabolism 80-90% metabolized in 30 minutes Constant rate 20 mg/dL per hour Rate may increase in chronic alcoholic 3-5% excreted unchanged through lungs and kidneys Remainder metabolized in liver to CO2 and H2O ETOH CNS depressant Peripheral vasodilator Suppresses ADH secretion Low doses have excitatory and stimulatory effect High doses to acute intoxication; respiratory arrest; hypotension; hypothermia Chronic Alcohol Abuse Drinks early in day/alone/secretly Periodic binges/blackouts GI problems/ “green tongue” syndrome Cigarette burns on clothing, linens Chronically flushed face/palms Alcohol Abuse Consequences of Chronic Alcohol Ingestion • Poor nutrition • Alcohol hepatitis • Liver cirrhosis, pancreatitis • Sensory loss in hands/feet • Loss of balance and coordination • Upper GI hemorrhage • Hypoglycemia • Falls (fractures and subdural hematoma) ETOH Withdrawal Syndrome 1st – 24-36 hrs – “rum fits”; seizures 2nd – 3rd day (*48-72 hrs after deprivation) Delerium Tremens DTs – decreased LOC with hallucinations Rx: ABC; chemstrip/BGL; IV; D50 and Thiamine 100 mg if hypoglycemic/Ativan for seizures The END