Substance Abuse/Toxicology  CME December 5, 2007 Samuel Kim Lawren Wellisch
Objectives <ul><li>Review signs & symptoms of substance abuse/overdose </li></ul><ul><ul><li>Opioids, Sedative-Hypnotics, ...
<ul><li>SIGNS & SYMPTOMS </li></ul><ul><li>OF </li></ul><ul><li>SUBSTANCE ABUSE / OVERDOSE </li></ul>
Opioids <ul><li>Examples: </li></ul><ul><ul><li>Rx painkillers (Demerol, Percocet, Vicodin, Oxycodone, Morphine, Codeine e...
Sedative-Hypnotics <ul><li>Examples: </li></ul><ul><ul><li>Benzodiapenes (Xanax, Valium, Rohypnol, Ativan etc.) </li></ul>...
Extra information on Alcohol From Mosby’s Paramedic Textbook, Revised Third Edition, Table 36-5
Anti-cholinergics <ul><li>Examples: </li></ul><ul><ul><li>Diphenhydramine (Benadryl) </li></ul></ul><ul><ul><li>Some Tricy...
Sympathomimetics / Stimulants <ul><li>Examples: </li></ul><ul><ul><li>Amphetamines/ Methamphetamines (“Meth”, Ecstacy, Spe...
Hallucinogens <ul><li>Examples: </li></ul><ul><ul><li>LSD (“acid”) </li></ul></ul><ul><ul><li>PCP </li></ul></ul><ul><ul><...
NSAIDS <ul><li>Examples: </li></ul><ul><ul><li>Ibuprofen (Advil) </li></ul></ul><ul><ul><li>Acetaminophen (Tylenol) </li><...
Protocols and General Standards of Care
RI Protocol: Poisoning and Overdose <ul><li>If pt is unconscious or has impaired consciousness, follow Impaired Consciousn...
RI Protocol: Impaired Consciousness <ul><li>Rule out trauma (C-spine immobilization, Spineboard) </li></ul><ul><li>Initial...
Activated Charcoal <ul><li>Indications </li></ul><ul><ul><li>Poisoning or overdose </li></ul></ul><ul><li>Dosage </li></ul...
Naloxone (Narcan) <ul><li>Indications </li></ul><ul><ul><li>Suspected narcotic overdose </li></ul></ul><ul><li>Dosage </li...
Syrup of Ipecac <ul><li>Indications </li></ul><ul><li>Dosage </li></ul><ul><ul><li>>8 y.o., 30mL PO followed by 8oz water ...
Sodium bicarbonate (NaHCO 3 ) <ul><li>Indications </li></ul><ul><ul><li>TCA overdose </li></ul></ul><ul><ul><li>Contact Me...
GENERAL STANDARDS OF CARE
ALWAYS!  HISTORY <ul><li>Baseline vitals </li></ul><ul><ul><ul><li>Respirations </li></ul></ul></ul><ul><ul><ul><li>Pulse ...
ALWAYS! HISTORY <ul><li>Five critical questions for substance abuse/intoxication calls: </li></ul><ul><ul><li>What substan...
ALWAYS! TREATMENT <ul><li>Provide oxygen </li></ul><ul><ul><li>Try to use nasal cannula if patient is at risk for vomiting...
ALWAYS!   EMT HEALTH AND SAFETY <ul><li>Protect yourself! </li></ul><ul><ul><li>Patients can be dangerous if they are beco...
Avoid Tunnel Vision <ul><li>Keep in mind that there may be factors unrelated to substance abuse contributing to the patien...
Contacting poison control <ul><li>Telephone Number </li></ul><ul><ul><li>Med control can also contact poison control for y...
SPECIAL CONSIDERATIONS for COMMON CALLS
Alcohol/EtOH Intoxication GUIDELINES FOR TRANSPORT TO UHS <ul><li>Transport to UHS is not permitted if: </li></ul><ul><ul>...
Alcohol/EtOH Intoxication GUIDELINES FOR REFUSALS <ul><li>Must be A&Ox4/4 </li></ul><ul><li>If patient chooses the refusal...
Illegal Substances SHOULD YOU TELL?? <ul><li>Patient confidentiality – EMTs are not permitted to reveal information from t...
Suicide Attempts ASSESSMENT <ul><li>This is now a psych call as well as a medical emergency.  Treat it as such! </li></ul>...
Suicide Attempts REFUSALS <ul><li>Best to persuade patient to accept treatment and transport </li></ul><ul><ul><li>Whether...
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Substance Abuse and Toxicology CME 2007

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  • Substance Abuse and Toxicology CME 2007

    1. 1. Substance Abuse/Toxicology CME December 5, 2007 Samuel Kim Lawren Wellisch
    2. 2. Objectives <ul><li>Review signs & symptoms of substance abuse/overdose </li></ul><ul><ul><li>Opioids, Sedative-Hypnotics, Anti-cholinergics, Sympathomimetics/Stimulants, Hallucinogens, NSAIDs </li></ul></ul><ul><li>Review RI protocols for poisoning/intoxication calls (general standards of care) </li></ul><ul><li>Discuss special concerns for common calls </li></ul><ul><ul><li>Alcohol intoxication </li></ul></ul><ul><ul><li>Drug use </li></ul></ul><ul><ul><li>Intentional overdose/suicide attempt </li></ul></ul>
    3. 3. <ul><li>SIGNS & SYMPTOMS </li></ul><ul><li>OF </li></ul><ul><li>SUBSTANCE ABUSE / OVERDOSE </li></ul>
    4. 4. Opioids <ul><li>Examples: </li></ul><ul><ul><li>Rx painkillers (Demerol, Percocet, Vicodin, Oxycodone, Morphine, Codeine etc.) </li></ul></ul><ul><ul><li>Heroin </li></ul></ul><ul><ul><li>Opium </li></ul></ul><ul><li>S/Sx: </li></ul><ul><ul><li>Hypoventilation </li></ul></ul><ul><ul><li>Pinpoint pupils (miosis) </li></ul></ul><ul><ul><li>Sedation/Coma </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul>
    5. 5. Sedative-Hypnotics <ul><li>Examples: </li></ul><ul><ul><li>Benzodiapenes (Xanax, Valium, Rohypnol, Ativan etc.) </li></ul></ul><ul><ul><li>Barbituates (phenobarbitol, amobarbitol etc.) </li></ul></ul><ul><ul><li>Alcohol* </li></ul></ul><ul><li>S/Sx: </li></ul><ul><ul><li>Slurred speech </li></ul></ul><ul><ul><li>Sedation/Coma </li></ul></ul><ul><ul><li>Hypoventilation </li></ul></ul><ul><ul><li>Hypotension </li></ul></ul><ul><ul><li>*-emesis </li></ul></ul><ul><ul><li>-hematemesis </li></ul></ul>
    6. 6. Extra information on Alcohol From Mosby’s Paramedic Textbook, Revised Third Edition, Table 36-5
    7. 7. Anti-cholinergics <ul><li>Examples: </li></ul><ul><ul><li>Diphenhydramine (Benadryl) </li></ul></ul><ul><ul><li>Some Tricyclic Anti-depressants (Elavil, Tofranil etc.) </li></ul></ul><ul><li>S/Sx: </li></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Hyperthermia </li></ul></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Dilated pupils (mydriasis) </li></ul></ul><ul><ul><li>Dry skin/ mucous membranes </li></ul></ul><ul><ul><li>Sedation/Agitation/ Seizures/Coma/Delirium </li></ul></ul><ul><ul><li>Decreased bowel sounds </li></ul></ul>
    8. 8. Sympathomimetics / Stimulants <ul><li>Examples: </li></ul><ul><ul><li>Amphetamines/ Methamphetamines (“Meth”, Ecstacy, Speed, “uppers”) </li></ul></ul><ul><ul><li>Cocaine/Crack </li></ul></ul><ul><li>S/Sx: </li></ul><ul><ul><li>Hypertension </li></ul></ul><ul><ul><li>Tachycardia </li></ul></ul><ul><ul><li>Dilated pupils (mydriasis) </li></ul></ul><ul><ul><li>Agitation/seizures </li></ul></ul><ul><ul><li>Hyperthermia </li></ul></ul>
    9. 9. Hallucinogens <ul><li>Examples: </li></ul><ul><ul><li>LSD (“acid”) </li></ul></ul><ul><ul><li>PCP </li></ul></ul><ul><ul><li>Psilocybin (Mushrooms, “shrooms”) </li></ul></ul><ul><ul><li>Marijuana* </li></ul></ul><ul><li>S/Sx: </li></ul><ul><ul><li>Similar to sympathomimetics </li></ul></ul><ul><ul><ul><li>Accompanied by hallucinations, delusions, paranoia </li></ul></ul></ul><ul><ul><li>*Usually produces euphoria, relaxation, drowsiness, short-term memory impairment. </li></ul></ul><ul><ul><li>Can progress to depression/confusion </li></ul></ul><ul><ul><li>Anxiety and panic can occur, especially in FIRST TIME USERS. </li></ul></ul>
    10. 10. NSAIDS <ul><li>Examples: </li></ul><ul><ul><li>Ibuprofen (Advil) </li></ul></ul><ul><ul><li>Acetaminophen (Tylenol) </li></ul></ul><ul><ul><li>Aspirin/ ASA* </li></ul></ul><ul><li>S/Sx: </li></ul><ul><ul><li>Ibuprofen and Acetaminophen are sometimes used for suicide attempts, but extremely high doses are needed to produce adverse affects. </li></ul></ul><ul><ul><ul><li>Ibuprofen: >300mg/kg “to produce mild effects” </li></ul></ul></ul><ul><ul><ul><ul><li>90 200mg pills in 60kg pt </li></ul></ul></ul></ul><ul><ul><ul><li>Acetaminophen: <140mg/kg “without serious effect.” </li></ul></ul></ul><ul><ul><ul><ul><li>25 325mg pills in 60kg pt </li></ul></ul></ul></ul><ul><ul><ul><ul><li>17 500mg pills in 60kg pt </li></ul></ul></ul></ul><ul><ul><li>*Aspirin overdose (acute or chronic) can be lethal </li></ul></ul><ul><ul><ul><li>Nausea/vomiting </li></ul></ul></ul><ul><ul><ul><li>Hyperventilation </li></ul></ul></ul><ul><ul><ul><li>“ ringing in the ears” </li></ul></ul></ul><ul><ul><ul><li>Risk of seizures </li></ul></ul></ul>
    11. 11. Protocols and General Standards of Care
    12. 12. RI Protocol: Poisoning and Overdose <ul><li>If pt is unconscious or has impaired consciousness, follow Impaired Consciousness protocol </li></ul><ul><li>Contact Poison Control (1-800-682-9211) or Med Control </li></ul><ul><ul><li>Activated Charcoal (1gm/kg PO) </li></ul></ul><ul><ul><li>Syrup of Ipecac (adult: 30mL PO + 8oz water) (ped: 15mL PO + 8oz water) </li></ul></ul><ul><li>ALS: monitor, IV </li></ul><ul><li>Transport </li></ul><ul><li>Bring “clues”: medications, vials, needles </li></ul><ul><li>Document </li></ul>
    13. 13. RI Protocol: Impaired Consciousness <ul><li>Rule out trauma (C-spine immobilization, Spineboard) </li></ul><ul><li>Initial assessment, ABCs; Left lateral position as indicated </li></ul><ul><li>Manage airway, respirations, (O2 as needed) </li></ul><ul><li>Obtain history from family/bystanders (including medications) </li></ul><ul><li>Physical Exam (AVPU/GCS, vital signs, pupils, med-alert tags) </li></ul><ul><li>Treat shock as indicated </li></ul><ul><li>ALS – monitor, IV </li></ul><ul><ul><li>bG<60mg/dL </li></ul></ul><ul><ul><ul><li>Thiamine (100mg IV) </li></ul></ul></ul><ul><ul><ul><li>D50 (25gm IV) or Glucagon (1mg IM/SQ) </li></ul></ul></ul><ul><ul><li>Narcan (2.0mg IV/IM/SQ) </li></ul></ul><ul><li>BLS </li></ul><ul><ul><li>bG<60mg/dL administer Glucagon (1mg) IM/SQ) </li></ul></ul><ul><li>Transport, Document </li></ul>
    14. 14. Activated Charcoal <ul><li>Indications </li></ul><ul><ul><li>Poisoning or overdose </li></ul></ul><ul><li>Dosage </li></ul><ul><ul><li>1 gm/kg (0.5 gm/lb) PO </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Ingestion of: </li></ul></ul><ul><ul><ul><li>Hydrocarbon </li></ul></ul></ul><ul><ul><ul><li>Petroleum distillate </li></ul></ul></ul><ul><ul><ul><li>A caustic substance </li></ul></ul></ul><ul><ul><li>Altered mental status </li></ul></ul><ul><ul><li>Inability to swallow </li></ul></ul>
    15. 15. Naloxone (Narcan) <ul><li>Indications </li></ul><ul><ul><li>Suspected narcotic overdose </li></ul></ul><ul><li>Dosage </li></ul><ul><ul><li>2.0 mg IV / IM / SQ, 3 min intervals or </li></ul></ul><ul><ul><li>0.4 mg IV / IM / SQ, 1 min intervals </li></ul></ul><ul><ul><li>Total dose of 10 mg </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Do not use in meperidine (MPPP)-induced seizures </li></ul></ul><ul><ul><li>Ped: 0.1 mg/kg IV / IM / SQ, 3 min intervals Total dose of 10 mg </li></ul></ul>
    16. 16. Syrup of Ipecac <ul><li>Indications </li></ul><ul><li>Dosage </li></ul><ul><ul><li>>8 y.o., 30mL PO followed by 8oz water </li></ul></ul><ul><ul><li><8 y.o., 15 mL PO followed by 4oz water </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Has no gag reflex </li></ul></ul><ul><ul><li>Is actively seizing or vomitting </li></ul></ul><ul><ul><li>Has ingested: </li></ul></ul><ul><ul><ul><li>Sharp object </li></ul></ul></ul><ul><ul><ul><li>Hydrocarbon </li></ul></ul></ul><ul><ul><ul><li>Petroleum distillate </li></ul></ul></ul><ul><ul><ul><li>Caustic substance (acid/alkali) </li></ul></ul></ul>
    17. 17. Sodium bicarbonate (NaHCO 3 ) <ul><li>Indications </li></ul><ul><ul><li>TCA overdose </li></ul></ul><ul><ul><li>Contact Med Control! </li></ul></ul><ul><li>Dosage </li></ul><ul><ul><li>1 mEq/kg IV </li></ul></ul><ul><li>Contraindications </li></ul><ul><ul><li>Hypocalcemia </li></ul></ul><ul><ul><li>Hypokalemia </li></ul></ul><ul><ul><li>Hypernatremia </li></ul></ul><ul><ul><li>Abd pain of unknown origins </li></ul></ul>
    18. 18. GENERAL STANDARDS OF CARE
    19. 19. ALWAYS! HISTORY <ul><li>Baseline vitals </li></ul><ul><ul><ul><li>Respirations </li></ul></ul></ul><ul><ul><ul><li>Pulse </li></ul></ul></ul><ul><ul><ul><li>Skin (color, temperature, moisture) </li></ul></ul></ul><ul><ul><ul><li>Capillary Refill </li></ul></ul></ul><ul><ul><ul><li>SpO 2 </li></ul></ul></ul><ul><ul><ul><li>Blood pressure </li></ul></ul></ul><ul><ul><ul><li>LOC </li></ul></ul></ul><ul><ul><ul><li>Pupils </li></ul></ul></ul><ul><ul><ul><li>Blood Glucose </li></ul></ul></ul><ul><ul><li>Deterioration can be rapid, make sure to keep track of patients LOC and note times on run report </li></ul></ul>
    20. 20. ALWAYS! HISTORY <ul><li>Five critical questions for substance abuse/intoxication calls: </li></ul><ul><ul><li>What substance(s) did you take? </li></ul></ul><ul><ul><li>When did you take it (become exposed to it)? </li></ul></ul><ul><ul><li>How much did you take? </li></ul></ul><ul><ul><li>What actions have been taken? </li></ul></ul><ul><ul><li>How much do you weigh ? </li></ul></ul><ul><li>SAMPLE </li></ul>
    21. 21. ALWAYS! TREATMENT <ul><li>Provide oxygen </li></ul><ul><ul><li>Try to use nasal cannula if patient is at risk for vomiting. </li></ul></ul><ul><li>Frequently Reassess </li></ul><ul><ul><li>Continual reassessment is especially critical for substance abuse/overdose calls. Be prepared to assist ventilations etc. </li></ul></ul>
    22. 22. ALWAYS! EMT HEALTH AND SAFETY <ul><li>Protect yourself! </li></ul><ul><ul><li>Patients can be dangerous if they are becoming belligerent, do not want treatment, or are suffering from delusions/paranoia. </li></ul></ul><ul><ul><li>If you feel threatened, protect yourself first. Remember, Scene Safety. </li></ul></ul><ul><ul><li>Request DPS assistance if necessary. </li></ul></ul>
    23. 23. Avoid Tunnel Vision <ul><li>Keep in mind that there may be factors unrelated to substance abuse contributing to the patient’s S/Sx </li></ul><ul><ul><li>Examples: </li></ul></ul><ul><ul><ul><li>Trauma </li></ul></ul></ul><ul><ul><ul><li>underlying psychological conditions </li></ul></ul></ul><ul><ul><ul><li>diabetic/medical emergencies </li></ul></ul></ul><ul><li>Never make assumptions, you may not know the whole story (could your patient have been “slipped” something?) </li></ul><ul><li>Don’t neglect treating all aspects of the patient’s condition </li></ul><ul><li>Consider the vulnerability of your patient if LOC or A&O status is compromised. </li></ul>
    24. 24. Contacting poison control <ul><li>Telephone Number </li></ul><ul><ul><li>Med control can also contact poison control for you. </li></ul></ul><ul><li>When to call </li></ul><ul><ul><li>Anytime you’re unfamiliar with the effects of the substance ingested. </li></ul></ul>
    25. 25. SPECIAL CONSIDERATIONS for COMMON CALLS
    26. 26. Alcohol/EtOH Intoxication GUIDELINES FOR TRANSPORT TO UHS <ul><li>Transport to UHS is not permitted if: </li></ul><ul><ul><li>Patient has used any substance besides alcohol </li></ul></ul><ul><ul><li>Patient is combative or unresponsive </li></ul></ul><ul><ul><li>Beds are unavailable in infirmary </li></ul></ul><ul><ul><li>Patient is not a Brown student (MUST present a BROWN ID!!) </li></ul></ul><ul><li>Transport decision is up to the supervisor </li></ul>
    27. 27. Alcohol/EtOH Intoxication GUIDELINES FOR REFUSALS <ul><li>Must be A&Ox4/4 </li></ul><ul><li>If patient chooses the refusal route, </li></ul><ul><ul><ul><li>Ensure there is someone to watch over the patient </li></ul></ul></ul><ul><ul><ul><li>Advise them to call EMS if condition changes/worsens </li></ul></ul></ul>
    28. 28. Illegal Substances SHOULD YOU TELL?? <ul><li>Patient confidentiality – EMTs are not permitted to reveal information from their assessments to anyone other than health care providers to whom that information is relevant </li></ul><ul><ul><li>Even if a law enforcement officer asks you if the patient admitted to using illegal substances! </li></ul></ul>
    29. 29. Suicide Attempts ASSESSMENT <ul><li>This is now a psych call as well as a medical emergency. Treat it as such! </li></ul><ul><li>Medical treatment will be the same as for other substance abuse/intoxication calls, but your assessment and bedside manner may need to be altered for the sensitive nature of this type of call. </li></ul><ul><ul><li>Consider: </li></ul></ul><ul><ul><ul><li>Documenting patient appearance/behavior (Well-groomed? Well-dressed? Cooperative? Combative?) Be clear on report and with other healthcare providers why you are suspicious of a suicide attempt. </li></ul></ul></ul><ul><ul><ul><li>Contacting Psychological Services </li></ul></ul></ul>
    30. 30. Suicide Attempts REFUSALS <ul><li>Best to persuade patient to accept treatment and transport </li></ul><ul><ul><li>Whether or not they specifically state suicidal intentions </li></ul></ul><ul><li>Otherwise, police can employ Protective Custody (PC) </li></ul><ul><ul><li>“ Last resort” – Is disempowering to the patient and can exacerbate the situation </li></ul></ul><ul><ul><li>May be the only option if substances are involved and reasoning is ineffective </li></ul></ul>

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