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Overdose 2016 Refresher J Temple Outcomes Gain a better understanding of some commonly abused / misused pharmaceuticals and their respective interventions “Study hard young people” Urine 1-5 days Hair Maybe 90 days (1/2 inch / month growth Oral fluids 10-24 hrs Sweat patch 7 days Art Project my butt! Party Drugs Thanks to: Linda G. Ramirez Manuel Ramirez NAEMSE • • • • • • • • • List includes but is not limited to. MDMA (ecstasy) LSD Methamphetamine GHB Ketamine Rohypnol Cocaine Also popular marijuana and alcohol. Ecstasy MDMA (3,4-methylenedioxy-Nmethylamphetaime) Street Names - Ecstasy, X, XTC, Adam, Essence. Marked as a feel good drug Produces profoundly positive feelings, empathy for others, elimination of anxiety and extreme relaxation. Suppress the need to eat, drink, sleep enabling ravers to endure all night, two or three day parties. Ecstasy What is it and how does it work? MDMA (3,4-methylenedioxymethamphetamine) An amphetamine analogue that produces euphoria, feelings of closeness to others and stimulant effects. Acts as a short term antidepressant by releasing large amounts of Serotonin (a neurotransmitter). Ecstasy What is it and how does it work? MDMA (3,4-methylenedioxymethamphetamine) An amphetamine analogue that produces euphoria, feelings of closeness to others and stimulant effects. Acts as a short term antidepressant by releasing large amounts of Serotonin (a neurotransmitter). • Names: XTC, X, E, Adam, Clarity, Lover’s Speed, hug-drug, E-bombs. • Method Used: Swallowed: tablet or capsule. Normal dosage --100-125 mg. • The “High”: Positive feelings and empathy for others, feelings of being close to others, decrease in anxiety, euphoria, decreased appetite, decreased thirst or need for sleep. Ecstasy Effects: Increased energy, nausea, hallucinations, chills, sweating, shaking, blurred vision, rapid heart beat, high blood pressure, muscle cramping. Serious Risks: Heat stroke, severe dehydration, possible changes in brain functioning, memory problems, serious depression. Ecstasy Caution: Mixing X with other drugs can lead to adverse reactions. Be aware that other drugs are sold as Ecstasy, but they are not (DXM, PMA). Eventually, you “run out” of Serotonin, regardless of how much you take. Ecstasy Reducing Risks: Make sure you know what you are taking (use a test kit, if possible). Taking more may not give you a greater high and may only increase negative side effects. Watch for overheating and dehydrating. Drink water and cool off! Ecstasy- Test Kit • Hours of physical activity (dancing) • No drinking…WATER! • Dehydration and hyperthermia! • Not usually the only drug these folks use! E f f e c t s Short Term Increase heart rate, blood pressure, and body temperature. Jaw and teeth clenching, dehydration, blurred vision, paranoia. Long Term Depression, sleep disorders, anxiety, paranoia, aggressive behavior. Ecstasy Painters mask used with inhalants to enhance the effects of Ecstasy. Vicks is rubbed around their nose and mouth to enhance the effect. Molly What is it? “Purified” MDMA Often combined or substituted with caffeine, dextromethorphan, amphetamines, cocaine, or PCP Desired Effects Both hallucinogenic and stimulant properties Mental stimulation, emotional warmth, decreased anxiety, euphoria, enhanced perceptions Dangers Muscle tension, increased heart rate and blood pressure, tremors, teeth clenching, depression Neurotoxicity, nephrotoxicity, cardiovascular toxicity, hyperthermia, seizures, intracranial hemorrhage Steinhardt et al. Ment Health Clin. 2014;4(5):64. NIDA for Teens. Drug Facts: MDMA. Available at: http://teens.drugabuse.gov/drug-facts/mdma-ecstasy-or-molly Powdered Alcohol What is it? Freeze-dried powder formulation of alcohol Most notably marketed in the US under the name Palcohol Labeling originally approved by the Alcohol and Tobacco Tax and Trade Bureau, but withdrawn days later Desired Effects Discreet means of intoxication Use on food products for “an extra kick” Snorting powder as a means of immediate intoxication** Dangers Over-consumption of alcohol, addictive potential, attractiveness to young children One packet = 5oz of booze added to water = 1 mixed drink http://time.com/71664/powdered-alcohol-palcohol-error/ http://www.cbsnews.com/news/palcohol-powdered-alcohol-may-present-serious-health-risks/ N-BOMe Substances What is it? 25I-NBOMe, 25C-NBOMe, and 25B-NBOMe Synthetic phenethylamines with effects similar to LSD Powders, liquids, edibles, blotter papers Desired Effects Street names: N-bomb, Smiles, Boom, Gnome, Dime, 25I, 25C, 25B Potent hallucinogenic activity Euphoria, loving feelings, enhanced awareness, sexual sensations/desires Dangers Psychosis, agitation, erratic behavior, depression, anxiety, paranoia Seizures, cardiac arrest, respiratory arrest, death http://www.etcada.com/events/designer-psychedelics-new-class-of-designer-drugs-in-harris-county http://www.deadiversion.usdoj.gov/drug_chem_info/nbome.pdf http://www.addictiontreatmentmagazine.com/synthetic-drugs/teen-seizures-and-deaths-linked-to-dangerous-designer-drug-n-bomb-part-1/ All Smiles Like mixing METH and LSD 5X more powerful than LSD 750 MCG is the standard dose 6 grains of table salt Usually snorted, inhaled, smoked, SL , rectally - no real effect if ingested! EXTREMELY toxic to responders! Use gloves and mask to handle! Powdered Caffeine What is it? Powdered form of pure caffeine One teaspoon is equivalent to approximately 28 cups of coffee Marketed as a dietary supplement Desired Effects Energy boost, weight loss Dangers Vomiting, diarrhea, stupor, disorientation Rapid and abnormal heartbeat, seizures, death http://www.fda.gov/Food/RecallsOutbreaksEmergencies/SafetyAlertsAdvisories/ucm405787.htm http://nypost.com/2014/07/19/powdered-caffeine-scrutinized-after-prom-king-dies/ http://seattletimes.com/html/health/2024115386_apxcaffeinepowderwarning.html 3.5 oz package (100g) Great… Absorbs in under 1 hour! Stable SVT – BENZOS and Beta blocker for rate Adenosine not effective here! Caffeine antagonizes Adenosine receptors. Hypokalemia Rhabdo Fluids to keep Kidneys working Where do People Obtain Prescription Drugs? 70% of people who abuse prescription medicine get them from a FRIEND or RELATIVE Why do People Abuse Prescription Drugs? Getting high Pain relief, anxiety and increase alertness Peer pressure Easy access Cheap, pure “Less harmful” Less likely risk of arrest Opiates Examples OxyContin® (oxycodone) Percocet® (oxycodone) MS Contin® (morphine) Duragesic® (fentanyl) Lortab® (hydrocodone) Vicodin® (hydrocodone) Norco® (hydrocodone) Codeine Opiates Signs of Abuse Sedation Fatigue Confusion Unconscious Coma Nausea Constipation Pinpoint pupils Slowed breathing Death Stimulants Examples Adderall® (mixed amphetamine salts) Concerta® (methylphenidate) Ritalin® (methylphenidate) Dexedrine® (dextroamphetamine) Stimulants – Signs of Abuse Dilated pupils Fast heart rate Fever Increased activity Aggression Panic Paranoia Psychosis Heart problems RITALIN Stimulant, prescribed for Narcolepsy, ADHD, and other medical issues Abusers relay that they begin to take other drugs to get rid of the horrible “come down” symptoms Ritalin is associated with a significant risk of developing a cocaine habit! Ritalin is manufactured legally, NOT made in street labs! Maybe $5-20 per pill Benzodiazepines Examples Xanax® (alprazolam) Valium® (diazepam) Ativan® (lorazepam) Klonopin® (clonazepam) Librium® (chlordiazepoxide) Restoril® (temazepam) Benzodiazepines – Signs of Abuse Benzodiazepines Drowsiness Clumsiness Fatigue Slowed thinking Slowed speech Memory problems Depression Slowed breathing Over the Counter (OTC) Medications Over the Counter drugs are: Drugs that do not require a doctor’s prescription Bought off the shelf in stores Regulated through the FDA Dextromethorphan (DXM) Commonly found in cough and cold medications Examples Robitussin® Dimetapp DM® Nyquil® Coricidin® Will usually have “tuss” in the name or end in “DM” DXM – Signs of Abuse Loss of coordination Slurred speech Disassociation Headache Nausea Vomiting Fast heart beat Numbness of fingers and toes Pseudoephedrine Major ingredient used to make methamphetamine Produces stimulant effects Increased blood pressure Fast heart beat Feeling nervous Restlessness Synthetic Legally Intoxicating Drugs Some compounds are now illegal Labeled “not for human consumption” to avoid FDA regulations Sold as bath salts or incense Were readily available at quick marts, head shops, and online Synthetic Cannabinoids Usually contain shredded plant matter Plant matter is treated with chemicals Plant matter usually has no psychoactive effects Smoked as an alternative to marijuana Can be made into tea May be sold as ‘incense’ Beta-Blocked Beta receptors B1: Heart Muscle inc. HR, contractility, AV conduction B2: Smooth Muscle (lungs, peripheral vasculature), Heart vasodilation, bronchodilation B3: Adipose Tissue, Heart cat. Thermogenesis?, dec. contractility? pathophysiology Direct Beta Blockade All BBs Membrane Stabilizing Activity (MSA): Propanolol, Acebutolol Fast Na Channel Inhibition (Heart) wide QRS Lipophilicity: Propanolol Cross BBB into CNS sz, delirium Intrinsic Sympathomimetic Activity (ISA): Partial B agonist activity less pronounced Sx PROPANOLOL: Nonselective beta blocker High MSA Lipophilic Rec. Dose in Thyroid Storm: 1-3mg IVP x1 Rec. Dose for Tachyarrythmia: 1-3mg IVP, MR x1 Half Life: 3-6hr, Duration 6-12hr Metabolism: Liver Clinical manifestations Sx within 6 hours of Ingestion Hypotension Bradycardia SHOCK Arrythmias Neuro: sz, delirium, coma Bronchospasm Hypoglycemia Treatment: The Basics 1. ABCs!!!! 2. Hypotension IVF, Pressors (more on this in a minute) 3. Bradycardia Atropine 0.5-1mg Q3-5min 4. Hypoglycemia D50 5. Seizures Benzos Treatment: Beyond the basics GLUCAGON Activates adenylyl cyclase increased CAMP increased Ca available for muscle contraction 5mg IV x1, MR x1 to assess for VS improvement If successful, start a 2-5mg/hr gtt SE: Vomiting CALCIUM CaCl 1g IVP (max: 3g) OR CaGlc 1g IV (max: 3g) Increase inotropy DATA: Case reports only Treatment: Beyond the basics II PRESSORS: Stimulate receptors to increase CAMP inotropy No good data, but recommended if necessary to maintain MAPs PDE INHIBITORS: Milrinone, Inamrinone Inhibit CAMP breakdown by PDE Data: isolated case reports only (although our patient did well!!) SE: GI, Hypotension, Arrythmias Puke-a-Palooza http://www.nbc.com/saturday-night-live/video/rookie-cop/2868167 Puke-a-Palooza You are called to the scene of an underground party at a local & deserted farm Dispatch informs you there are at least2 people not breathing As you find your 2 patients, you are informed that there are more patients spread throughout the scene that have altered level of consciousness or are unresponsive What do you do??? 61 Puke-a-Palooza 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 62 Yak-Fest 2016 63 YAK Management If you have enough BVM’s but not enough crew members for every patient, what could you do? How would you recruit additional help to ventilate patients? (ie: other party goers, police, who???) If you do not have enough suction units to be used one-on-one, what could you do to prevent aspiration? Go back to basics – positioning patient (side lying) Rude Awakening You have 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 your general impression? Cardiac patient until proven otherwise Considering the age and presentation, you need to consider cocaine ingestion 65 Rude Awakening You have started ALS care on this patient IV – O2 – Monitor Interpretation? Sinus tachycardia Any other interventions you would initiate? Possibly aspirin, denies chest pain so no nitroglycerin at this point 66 Rude Awakening During the call you now observe the following on the monitor: Impression? ST elevation (only evident on Lead II for now) Need to obtain a 12 lead EKG Update report to Medical Control 67 Rude Awakening Impression of 12 lead EKG? Inferior wall MI – ST elevation II, III, aVF 68 Case Scenario #4 Vital signs, pain scale, complete history if not previously obtained Ask Aspirin about use of illicit drugs (ie: cocaine) – if not previously administered Nitroglycerin if chest pain is present, blood pressure adequate, and no Viagra use 69 FLAKKA What is the intended effect of FLAKKA? Enhanced concentration Mood elevation Increased energy Elevated libido and decreased inhibitions Euphoria FLAKKA Flakka is made in labs overseas and sold to dealers over the internet A ‘hit” from a dealer can be sold for $5 or less How is FLAKKA Taken? Flakka can be: Snorted Smoked in joints, pipes or e-cigarettes Swallowed in capsules Injected What are the side effects of FLAKKA? Hallucinations Paranoia Psychosis Decreases inhibitions (unsafe sex) Anxiety Violence Self-destruction Insomnia High Temperature Excited Delirium Death (20 Broward County Deaths since September)
