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Illicit Drug EmergenciesECRN Mod II CE

Condell Medical Center EMS System

2 hours CE CreditSite Code #107214E-1211

Prepared by: Lt. William Hoover, Medical OfficerWauconda Fire District

Reviewed/revisions by: Sharon Hopkins RN, BSN, EMT-P

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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.

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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.

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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.

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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

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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

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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

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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

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Poison Control Center240per day/7 days per week

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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

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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

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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

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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

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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

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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

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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).

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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

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Heroin

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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

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Black Tar Heroin

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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

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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

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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

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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

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Heroin…

• http://youtu.be/Hj6NvwDLjAE• http://youtu.be/6mSq69FT3jM

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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)

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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

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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

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Cocaine

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Crack Cocaine

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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

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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

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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

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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!

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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

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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

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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

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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

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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

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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

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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

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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

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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

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Crystal Meth

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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

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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

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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

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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.

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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.

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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.

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Meth Labs – A Dangerous Place

• Typical products used

• Explosive environments

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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

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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

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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

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Ecstasy

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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

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Ecstasy: Treatment

• Normal scene safety precautions• ABC’s• IV, O2, and EKG monitor

• Monitor temperature

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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®

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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

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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

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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

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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

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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?

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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

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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?

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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

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Case Scenario #1Lessons learned

Narcan works on narcoticsHeroin, 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 lethalAspiration 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

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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

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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

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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?

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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

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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 ownThis 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

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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?

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Case Scenario #3EMS 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

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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)

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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?

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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 #4Impression 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• 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