Acute services and substance misuse: poisoning or overdose

1. Acute services &
substance misuse:
poisoning or overdose

2. What’s the problem?
• Harm from substance misuse (intentional or unintentional) including
alcohol and drugs account for a high percentage of acute
presentations although it is difficult to identify actual numbers as
coding may identify them as assaults, accidents or unknown
presentations.
• Alcohol-related admissions to hospital in 2012/13 alone amounted to
over 1 million (HSCIC, 2014).
• Many individuals present as disoriented, confused or with an altered
consciousness level. This makes assessment and management
challenging.
• The importance of bystanders, friends, family, emergency services
etc. for history cannot be underestimated.
• Safeguarding of individuals and on-going referral is critical to care.

3. Before reaching Accident &
Emergency
• There should be concern regarding poisoning or overdose for anyone
who appears drowsy, disoriented, behaving strangely or is physically
unwell (sweating, headache, vomiting etc) and where there is reason
to believe the person has taken a harmful substance.
• The most important first aid action should be to obtain specialist
professional assessment for the person by phoning the emergency
services.
• There are few other first aid actions necessary apart from calling for
an ambulance.
• However, obtaining a history of what has been taken - what, how,
when, how much - is very useful for the assessment process and risk
management.
• Be aware that telephone triage is available. You will not be wasting
ambulance service time if you are genuinely concerned. The operator
will assess (triage) the seriousness of the person’s condition and
advise you.

4. Case Study 1: Mandy
• Mandy is 24 and is brought to hospital by her friends who are
concerned about her. She is disorientated, sweating profusely and is
behaving strangely.
• She has consumed a lot of alcohol during the evening and her
friends think she has also been taking pills that she purchased in a
club. They have not taken any and don’t know what it is she has
taken.
• Mandy is incoherent and unable to confirm or deny ingestion of any
specific substances.

5. Case study 1: Mandy’s assessment
Instigate the acute management process:
• Immediate assessment on arrival: Manchester Triage System
(adopted by most UK emergency departments) has several
flowcharts relating to this kind of presentation including behaving
strangely, self-harm, and overdose.
• Whichever flowchart is followed, the priority is to ascertain as
complete a history as possible and rule out life threatening issues or
complications using a systematic approach.

6. The Manchester triage system
IMMEDIATE
VERY
URGENT
URGENT
STANDARD
NON-
URGENT
This system establishes the level of priority required:

7. Ruling out life threatening
emergencies

8. ABCDE: a systematic approach to
patient assessment
• A – AIRWAY
• B – BREATHING
• C – CIRCULATION
• D – DISABILITY
• E – ENVIRONMENT
This is an effective way to assess
the risk to the person. This can be
done in the community during a
crisis situation as well as in an
acute care setting.
The ABCDE system helps break
down the assessment of threat to
the person.

9. ABCDE: some examples
associated with substance use
• Airway: an unconscious
intoxicated person may vomit
which blocks the airway. Or
they may lie in an awkward
position which impedes
breathing.
• Breathing: opiate overdose
causes respiratory depression:
the person’s breathing may be
slowed or arrested.
• Circulation: an unconscious
person may lie for long periods
on a limb and cut off circulation.
Stimulant intoxication may bring
on a cardiac or cerebral event.
• Disability: an unconscious
person cannot defend
themselves from harm.
They may be at risk of
accident, hypothermia or
even hyperthermia.
• Environment: the person
may be in an unsafe
environment. As above,
they may be at risk of
hypothermia if outdoors, or
being run over. If behaving
strangely, they may take
risks due to psychosis or a
diminished sense of
danger.

10. Assessment of Mandy: A & E
process
• Airway - is it clear and patent? Record oxygen saturation.
• Breathing - is she breathing? Record respiratory rate and depth,
colour of patient.
• Circulation - what is her heart rate, blood pressure, temperature
and capillary refill time?
• Disability - how alert is she and are her pupils equal and reactive
to light and what size are they (pupil size may indicate drug
intoxication pinpoint is associated with opiates and dilated pupils are
associated with amphetamine type drugs) Record blood glucose (to
exclude diabetic coma).
• Environment – is she in the safest environment, are the right team
members present? Has an accurate history been taken from the
friends?

11. Assessment of Mandy
• Mandy has a raised temperature of 38.9, respiratory rate= 30, oxygen
saturation is 92% on air, raised pulse= 110 regular, normal/low blood
pressure = 100/60, capillary refill is 2 seconds, blood glucose is
5.2mmols, pupils are dilated but equal and reactive.
• She is agitated and is disorientated to time and place.
• There is no sign of obvious injury.

12. Assessment of Mandy (cont.)
Differential diagnosis for Mandy: what else could be causing these
signs and symptoms?
• ‘Behaving strangely’ may have a number of potential causes
including:
– Hypoglycaemia or ketoacidosis (from diabetic imbalance of
sugar/insulin)
– Raised intracranial pressure from a head injury
– Post ictal (following a seizure)
– Electrolyte imbalance/ acute dehydration from a range of acute
conditions including sepsis
– Acute psychiatric disorder
– Alcohol withdrawal
– Drug toxicity

13. Diagnosis for Mandy
• All these other possibilities need to be ruled out/in as substance
toxicity can mimic several common conditions.
• Mandy is fortunate that her friends were able to give some history of
her condition. However, no one knows exactly what she may have
taken or how it may interact with the alcohol.
• With many new psychoactive substances (‘legal highs’) being used
for recreational drug taking, the substance could be from a wide
range of harmful chemicals.
• If the substance cannot be identified, staff can consult the National
Poisons Information Service for advice.
• A new substance in circulation which causes problems needs to be
identified and warnings issued to the community, police and health
agencies.

14. Mandy’s immediate management
needs
• Maintain the safety of Mandy and other individuals around her.
• Nurse in a quiet but easily observed environment.
• Give oxygen on admission 15 litres via non rebreathing mask if
tolerated
• Cannulation for samples to test bloods urea and electrolytes, full
blood count, glucose, blood alcohol and blood gases.
• Give intravenous fluids and monitoring urine output.
• Contact Mandy’s next of kin and identify as soon as possible any
relevant medical history, allergies or medication.
• Observe and record observations (blood pressure, temperature,
respiration rate, pulse) half hourly reporting any deterioration in
Mandy’s conscious level or physiological status.
• If Mandy’s condition deteriorates she may require assessment by
intensive therapy team.

15. Mandy: 4hrs after admission
• Mandy is observed for a period of four hours and in that time
becomes less agitated and more alert.
• She is now able to tell staff that she had bought two pills believing
them to be ‘Molly’ (MDMA/ecstasy) but she had not purchased
anything from this individual before so couldn’t confirm exactly what
she had taken.
• She admits to regular recreational drug use including cocaine,
amphetamines and new psychoactive substances (NPS).
• Her clinical observations are within normal limits and staff can
consider discharging her.
Mandy: after stabilisation
• Once Mandy is stable and moved from immediate and very urgent
care, blood and urine tests may establish what type of substance is
involved.
• However, note that the immediate concern has been to ensure her
immediate risks are managed and minimised.

16. References & additional resources
• Caroline N (2013) Emergency Care in the Streets. American Academy of Orthopaedic
Surgeons, College of Paramedics. London, Jones & Bartlett.
• De Lacy J (2011) Improving the Assessment and Triage of Patients with Mental
Illness attending the Accident and Emergency Department. Royal College of
surgeons in Ireland. Available at:
http://epubs.rcsi.ie/cgi/viewcontent.cgi?article=1005&context=mscttheses
• Downing P (Ed) (2009) Emergencies in Adult Nursing. Oxford. Oxford University
Press.
• HSCIC (2014) Statistics on Alcohol England. Available at:
http://www.hscic.gov.uk/catalogue/PUB14184
• National Poisons Information Service (NPIS) available at: http://www.npis.org/