Alcohol Substance Abuse
1
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
2
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
3
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
4
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
5
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
6
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!
7
Alcohol continued
 < 0.08 (80) - legal limit in California
 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
8
Alcohol continued
 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
9
Alcohol Withdrawal
 With abrupt cessation of alcohol after prolonged
ingestion, there is an overreaction of the brain and
other mechanisms
 Early symptoms can start 6-8 hours after last drink
 Delirium Tremons can last 2-7 days
 Treatment is benzodiazepines and possibly ICU
admission
 SEIZURE PRECAUTIONS
10
Commonly Abused Depressant
Drugs
 Narcotics/opiates
 CNS depression
 Heroin
 Hydromorphine
 Darvon, Darvocet
 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
11
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
12
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).
13
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
14
Heroin
15
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
16
Black Tar Heroin
17
Treatment of Heroin
 Scene 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
18
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
19
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 our 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
20
Heroin…
 http://youtu.be/Hj6NvwDLjAE
21
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
22
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
23
Cocaine
24
Crack Cocaine
25
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 noncocaine users
 Increase QRS voltage indicative of ventricular
enlargement
 Conduction delays resulting in widening of the QRS and
prolonged QT segment
26
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
27
Cocaine: Signs & Symptoms
 Paranoia
 Dilated pupils
 Dry mouth/nose
 Hyperactivity
 Tachycardia
 Euphoria
 Hypertension
 Irritability
 Disturbance of heart rhythm
 Anxiety
 Chest pain
 Excessive talking
 Heart failure
 Depression or excessive sleeping
 Respiratory failure
 Long periods without eating or sleeping
 Strokes/seizures
 Weight loss
28
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!
29
Cocaine: Restraints
 Restraints have been implicated as a contributing
factor for user deaths during prone restraint
 Sudden death appears to have been induced by
a combination of three factors that increases
oxygen demand and decreases oxygen delivery
 See next slide
30
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
31
Cocaine: Treatment
 Make certain the scene 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
32
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
33
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
34
Benzodiazepines
 Tranquilizers
 Valium®
 Librium®
 Xanax®
 Halcion®
 Ativan®
 Diazepam (Valium®) may be fatal
when mixed with alcohol, opiates,
and other depressants
 Nearly impossible to take a fatal dose of Valium® when not
mixed with any other product, especially alcohol
35
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
36
Methamphetamine
 To control production of methamphetamine from
over-the-counter products, controls 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
37
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
38
39
Crystal Meth
40
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
41
Crystal Meth: Signs &
Symptoms
•
Dilated pupils
•
Weight loss
•
Dry mouth
•
Increased HR, BP &
Temperature
•
Euphoria
•
Restlessness
•
Decreased appetite
•
No interest in food or sleep.
•
Rapid speech
•
Violent
•
Paranoia
•
Irritability/Argument
•
Depression
•
Nasal congestion
•
Insomnia
42
Crystal Meth: Treatment
 Scene safety
 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
43
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.
44
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.
45
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.
46
Meth Labs – A Dangerous Place
 Typical products used
 Explosive
environments
47
Club/Rave/Party Drugs
 Very popular in universities, 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
48
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
49
Ecstasy: Background
 Is taken orally – pill form with multiple logos
 May cause psychological addiction
 Polydrug use often involved
 Mix of a variety of chemicals simultaneously taken
 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
50
Ecstasy
51
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
52
Ecstasy: Treatment
 Normal scene safety precautions
 ABC’s
 IV, O2, and EKG monitor
 Monitor temperature
53
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®
54
Synthesized Marijuana
 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
55
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
56