STREET DRUGS / OVERDOSE
Transcript of STREET DRUGS / OVERDOSE
STREET DRUGS / OVERDOSEPresented By:
Steven Jones, NREMT-PCLEMC Training Officer
Drug Abuse
Drug Abuse:Self administration of drug or drugs in manner not in accordance with accepted medical or social patterns
Drug Abuse
• Psychological Dependency (Habituation)• Drug necessary to maintain user’s
sense of well-being• Physical Dependency
• Physical symptoms if intake reduced
Drug Abuse
• Compulsive Drug Use• Preoccupation with obtaining drug• Rituals of preparing, using drug as important as
drug effects• Tolerance
• Increasing doses needed to obtain drug effect
Drug Abuse• Addiction
• Includes• Psychological dependence• Physical dependence• Compulsive use• Tolerance
• Plus, complete absorption with obtaining, using drug to exclusion of all else
Drug Abuse
• Suspect drug-related problem in patients with:• Altered LOC• Bizarre behavior• Seizures
Drug Abuse
• Ask EVERY patient about recreational drugs.• Be non-judgmental.• Keep drug box/cabinet secured.• Use discretion.• If held up, give them what they want!
Narcotics
• Opium• Opium derivatives• Synthetic opium substitutes
Narcotics
• Examples• Opium• Morphine• Heroin• Codeine• Dilaudid
• Oxycodone (Percodan)
• Meperidine (Demerol)• Propoxyphene
(Darvon)• Talwin• Fentanyl
Narcotics• Effects
• Analgesia• CNS depression
• Euphoria• Drowsiness• Apathy
• Antidiarrheal action• Antitussitive action
Narcotics• Overdose
• Mild to Moderate• Lethargy• Pinpoint pupils• Bradycardia• Hypotension• Decreased
bowel sounds• Flaccid muscles
Severe Respiratory depression Coma Aspiration Seizures with certain
compounds (meperidine, propoxyphene, tramadol)
Narcotics
• Overdose• Management
• Support oxygenation/ventilation• Vascular access• Narcan 2.0 to 4.0 mg
• Improve respirations• Do NOT awaken completely• Restrain before giving
Narcotics
• Associated Dangers• Skin abscesses• Phlebitis• Sepsis• Hepatitis• HIV• Endocarditis
• Adulterant toxicity
• “Cotton fever”• Malnutrition• Tetanus• Malaria
Narcotics• Withdrawal
• Insomnia• Restlessness• Irritability• Anorexia• Tremors• Back, extremity pain
• Watery eyes• Yawning• Rhinorrhea• Sneezing• Diarrhea• Diaphoresis
Resembles Severe Influenza
Narcotics• Withdrawal
• Lasts 7 to 10 days• NOT life threatening
Sedative-Hypnotic Drugs
Categories• Barbiturates• Benzodiazepine• Barbiturate-like non-barbiturates• Chloral hydrate
Mechanism of Action• Most overdoses of sedative-hypnotics are
from benzodiazepines, barbiturates• Both enhance effects of gamma-
aminobutyric acid (GABA)• GABA enhancement results in down-
regulation of CNS activity
Sedative-Hypnotics• Use more then a week leads to tolerance
to effects on sleep patterns• Withdrawal after long term results in
“rebound” increase in frequency of occurrence, duration of REM sleep.
• In high doses, sedative-hypnotics depress CNS to point of Stage III or general anesthesia
Sedative-Hypnotics
• Tolerance• Happens with all sedative-hypnotics• Appears very quickly even during short-term use.• Discontinuation will bring receptor response back
to normal after drug has been metabolized• Withdrawal symptoms may take up to a week to
see in some patients
Chloral Hydrate
• “Micky Finn” when mixed with alcohol• Rapidly absorbed, acts quickly• Drowsiness, sleep• Alcohol, chloral hydrate compete for metabolism by
same enzyme• Prolonged action for both when mixed• Not commonly abused
Barbiturates• Introduced in 1903• Replaced older sedative-hypnotics• Quickly became major health problem• In 1950’s-60’s barbiturates were
implicated in overdoses; were responsible for majority of drug-related suicides
Barbiturates
• Short-acting• Amytal• Pentathiol
• Intermediate-acting• Nembutal• Seconal• Tuinal
• Long-acting• Phenobarbital
Barbiturates
• Initial overdose presentation • Slurred speech• Ataxia• Lethargy • Nystagmus• Headache • Confusion
Barbiturates• As overdose progresses
• Depth of coma increases• Patient anesthetized with loss of neurologic
function• EEG may mimic brain death
• Respiratory depression occurs• Peripheral vasodilation occurs
• Hypotension, shock• Hypothermia
• Blisters (bullae) form on skin
Barbiturates• Early deaths
• Respiratory arrest• Cardiovascular collapse
• Delayed deaths• Acute renal failure• Pneumonia• Pulmonary edema• Cerebral edema
Barbiturates• Overdose management
• Secure airway• Support oxygenation/ventilation• IV with NS• Prevent heat loss secondary to vasodilation• Bicarbonate to alkalinize urine (long-acting only)
Barbiturates
• Withdrawal signs/symptoms• Apprehensiveness• Anxiety• Tremulousness• Diarrhea• Nausea• Vomiting• Seizures
Barbiturate-like, non-barbiturates• Examples
• Doriden (glutethimide)• Quaalude (methaqualone)• Placidyl (ethchlorvynol)• Noludar
• Overdose produces sudden, prolonged apnea• Highly addictive• Withdrawal resembles barbiturate withdrawal• Only Placidyl, Doriden remain available in U.S.
Placidyl (ethchlorvynol)• “Pickles”, “jelly beans”, “Mr. Green Jeans”• Produces vinyl-like odor on breath• Concentrates in CNS, slow hepatic metabolism• Half-life >100 hrs• Prolonged deep coma (100 to 300 hrs), hypothermia,
respiratory depression, hypotension, bradycardia• EEG is flatline (asystole)• Keep patient on life support for a few days; they wake
up, are ok
Doriden (gluthethimide)
• Abused in combination with codeine• “sets”, “hits”, “loads”, “fours and doors”• Prolonged coma (average 48 hours)• Hypotension, shock common• Anticholinergic signs: dilated pupils, tachycardia, dry
mouth, ileus, urinary retention, hyperthermia
Benzodiazepines
Benzodiazepines
• Developed due to overdoses, deaths related to barbiturates, barbiturate-like non-barbiturates
• Relatively few deaths• In 1993, prescription rate for barbiturates dropped to
one-sixth that of benzos
Benzodiazepines• Examples
• Valium (diazepam)• Ativan (lorazepam)• Versed (midazolam)• Librium (chlorodiazepoxide)• Tranxene (chlorazepate dipotassium)• Dalmane (flurazepam)• Halcion (triaxolam)• Restoril (temazepam)• Xanax (Alprazolam)
Benzodiazepines
• Adverse Effects• Weakness• Headache• Blurred vision• Vertigo• Nausea• Diarrhea• Chest pain
Benzodiazepines
• Overdoses• Relatively safe taken by themselves, even in
overdose• Can be lethal with other CNS depressants
especially alcohol • Look like other CNS depressant overdoses• Antidote is Romazicon (flumazenil)
• Not approved in CLEMC protocols• Only recommended in known, controlled
situations• Can lead to seizures that cannot be controlled
Benzodiazepines• Produce withdrawal syndrome similar to
barbiturate withdrawal
Benzodiazepine-like non-benzos• BuSpar (buspirone)
• Used for generalized anxiety disorder• Less sedating than diazepam• Less potentiation by other CNS
depressants• Ambien, Stilnox (zolpidem)
• Used for short-term insomnia treatment• Toxic effects similar to benzos
Neuroleptics• Antipsychotics, major tranquilizers• Used in treatment of schizophrenia, other psychoses• Examples
• Haldol• Mellaril• Thorazine• Stellazine• Compazine
Neuroleptics
• Extrapyramidal muscle contractions (dystonias)• Bizarre, acute, involuntary movements, spasms of
skeletal muscles• Reversible with Benadryl
Neuroleptics
• Acute Overdose Presentation• CNS depression• Hypotension• Anticholinergic symptoms: flushing, dry mouth,
hyperthermia, tachycardia, urinary retention• Ventricular arrhythmias, including Torsades• Seizures
Neuroleptics
• Acute Overdose Management• ABCs• Fluid, vasopressors for hypotension• Lidocaine for ventricular arrhythmia• Magnesium Sulfate for Torsades• Diazepam for seizures
Neuroleptics
• Neuroleptic malignant syndrome• Life-threatening reaction• Signs, symptoms
• Hyperthermia• Muscular rigidity• Altered LOC• Tachycardia, hypotension
Neuroleptics
• Neuroleptic malignant syndrome• Management
• ABCs• Oxygen• Assist ventilation, as needed• Benzodiazepines• Rapid cooling• Volume for hypotension
Stimulants
• Examples• Cocaine• Amphetamines
• Benzedrine (bennies, beans)• Dexedrine (dexies, copilots)• Methamphetamine (crystal meth, ice)
• CLOSELY WATCH BODY TEMPERATURE! PREPARE FOR RAPID COOLING.
• Ephedrine• Caffeine• Ritalin (Adderal)
Stimulants
• Produce • euphoria• hyperactivity• alertness• sense of enhanced energy• anorexia
Stimulants• Overdose signs/symptoms
• Euphoria, restlessness, agitation, anxiety• Paranoia, irritability, delirium, psychosis• Muscle tremors, rigidity• Seizures, coma• Nausea, vomiting, chills, sweating, headache• Elevated body temperature• Tachycardia, hypertension• Ventricular arrhythmias
Stimulants• Overdose complications
• Hyperthermia, heat stroke • Hypertensive crisis• CVA• Acute MI• Intestinal infarctions• Rhabdomyolysis• Acute renal failure
Stimulants
• Chronic effects• Weight loss• Cardiomyopathy• Paranoia• Psychosis• Stereotypic behavior: picking at skin
(“cocaine bugs”)
Stimulants• Overdose management
• Oxygen, monitor, IV• Valium for sedation• Hypertension control
• Avoid beta-blockers, including labetolol (Why?)• Body temperature reduction
Stimulants• Withdrawal
• Drowsiness• Profound depression (“cocaine blues”)• Increased appetite• Abdominal cramps, diarrhea, nausea• Headache
Hallucinogens
Hallucinogens
• Examples• Indole hallucinogens
• LSD (acid)• Morning-glory
seeds• Psilocybin• DMT
• Amphetamine-like hallucinogens
• Peyote• Mescaline• DOM• MDA• MDMA (ecstasy)
Hallucinogens
• Produce altered/enhanced sensation• Effects highly variable depending on patient• Increased dose does not intensify effect• Toxic overdose virtually impossible
Hallucinogens• Some patients may experience “bad trips”• Depends on surroundings, emotional state• Signs and symptoms
• Paranoia, fearfulness, combativeness• Anxiety, excitement• Nausea, vomiting• Tachycardia, tachypnea• Tearfulness• Bizarre Reasoning
Hallucinogens
• Moderate Intoxication• Tachycardia• Mydriasis• Diaphoresis• Short attention span• Tremor• Hypertension• Hyperreflexia• Fever
Hallucinogens
• Life-threatening toxicity (rare)• Seizures• Severe hyperthermia• Hypertension, arrhythmias• Obtunded, agitated, or thrashing about• Diaphoretic, hyperreflexic• Untreated hyperthermia can lead to hypotension,
coagulopathy, rhabdomyolysis and multiple organ failure
Hallucinogens
• Management of “bad trip”• Rule out other causes of hallucinations
• Hypoglycemia• Alcohol, drug withdrawal• Infection
• Quiet, supportive environment• Benzodiazepines, haldol for agitation, anxiety
Phencyclidine (PCP)
• Street names• Angel dust• Peace Pill• Hog • Krystal• Animal tranquilizer
• Used as veterinary anesthetic
Phencyclidine (PCP)
• Actions• Dissociative anesthesia• Generalized loss of pain perception• Little or no depression of airway reflexes or
ventilation• CNS-stimulant, anticholinergic, opiate, and alpha-
adrenergic effects
Phencyclidine (PCP)
• Low Doses• Lethargy, euphoria, hallucinations• Slurred speech• Blank stare• Insensitivity to pain• Midposition to dilated pupils• Vertical and horizontal nystagmus• Occasionally bizarre or violent behavior
Phencyclidine (PCP)
• Localized dystonic reactions
• Wide-eyed coma• Rigidity• Seizures
• High Doses• Diaphoresis• Salivation• Hypertension• Tachycardia• Hyperthermia
Phencyclidine (PCP)
• Treatment• Maintain airway• Assist ventilations, as needed• Treat coma, seizures, hypertension, hypothermia
as needed• Quiet environment• Sedation if needed to control agitation
• Geodon• Benzodiazepines
Inhalants• “Huffing” - the dangerous practice of
inhaling volatile chemicals to produce euphoric effects.
Inhalants• Examples
• Hydrocarbons (solvents, paints, aerosols)• Gases (freon, halon fire extinguishing agent)• Metallic paints (“huffing”)
“Huffing” is becoming increasingly popular among younger children.
Inhalants• Effects
• Dysrhythmias including VF• CNS depression• Seizures• Respiratory irritation• Epinephrine may increase risk of dysrhythmias
• Treatment• Oxygen• Treat symptomatically
Inhalants
“Date rape” drugs• Flunitrazepam (Rhohypnol)• Gamma hydroxybutyrate (GHB)
Flunitrazepam (Rhohypnol)
• Street names• Rophies• Roofies• R2• Roofenol
• Roche• Roachies • La rocha• Rope• Rib
Flunitrazepam (Rhohypnol)• Benzodiazepine• Similar to Valium but 10x more potent• Produced, sold legally in Europe, South America• Uses
• Short-term treatment of insomnia• Sedative hypnotic• Preanesthetic medication
Flunitrazepam (Rhohypnol)• Effects
• Disinhibition and amnesia• Onset within 30 minutes, peak within 2 hours, may
persist 8 hours or more• Frequently abused with alcohol or other drugs• Enhances high produced by heroin
Flunitrazepam (Rhohypnol)• Adverse Effects
• Drowsiness• Dizziness• Confusion• Decreased BP• Memory impairment• GI disturbances• Excitability, aggressive behavior
Flunitrazepam (Rhohypnol)• Management of overdose
• Lethal overdose very unlikely• Oxygenate, ventilate• Intubate if necessary to control airway• Vascular access• ECG• Fluid for hypotension• Dextrostick (rule out hypoglycemia)• Treat trauma resulting from assault
Flunitrazepam (Rhohypnol)
• Withdrawal• Headache• Anxiety, tension• Numbness, tingling
of extremities• Restlessness,
confusion• Loss of identity
• Hallucinations• Delirium• Seizures (up to a
week after cessation)• Shock• Cardiovascular
collapse
Flunitrazepam (Rhohypnol)• Management of withdrawal
• Oxygen/ventilation• Intubate if necessary• EKG• Vascular access• Fluid for hypotension• Dextrostick• Diazepam for seizures
Gamma hydroxybutyrate (GHB)• Street names
• Cherry meth• Liquid X• Liquid ecstacy
• Originally developed as anesthetic• Banned in 1991 because of side effects• Promoted as aphrodisiac
Gamma hydroxybutyrate (GHB)• Effects
• Odorless, nearly tasteless• Tremors• Seizures• Death
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