course material

1. Clinical Case
Clinical Case At 7:30pm on a Sunday evening, Sophia has called your Australian Ambulance
Service after coming home to find her boyfriend Vincent, a 32 year old construction worker
lying on the floor œunconscious•. On arrival at the scene you find Sophia, Vincent and
another male (Johnny) in the house. Sophia and Johnny are conscious, talking and walking
around the room, while Vincent is lying on the floor cyanosed and barely breathing. You
commence an initial treatment plan which involves administering oxygen to Vincent and
undertaking an initial assessment which reveals: Level of consciousness Does not respond
to verbal commands, responds to painful stimuli by grimacing, drawing away and making
unintelligible noises, his eyes remain closed (ie GCS 7). Airway and breathing Airway is
clear. Respiration 4 breaths/min, regular but shallow Circulation Radial pulse is ~34
beats/min, weak, but regular. Question 1 “ Discuss in point form: The key clinical feature of
the scenario that lead you to administer oxygen. The physiological rationale for
administering oxygen. The intended outcomes of administering oxygen. (7.5 Marks) While
undertaking this initial assessment, you observe a large number of empty spirit bottles
around the room, and notice puncture marks in Vincent’ s right arm. You attach a 3-lead
cardiac monitor and perform a physical examination, which reveals: Symptoms Severely
decreased level of consciousness, pin point pupils, cold to touch and centrally cyanosed.
Breathing sounds Nil adventitious sounds Blood pressure 69/38 mmHg Pulse 60 beats/min,
regular Respiration Ventilated at 12 bpm Oxygen saturation 98% (on 100% oxygen)
Initially Johnny and Sophia are reluctant to discuss what has happened with you, but once
they realize that the ambulance has attended alone without the police, they begin to open
up: Events leading to the call (from Johnny) œ¦I came over Friday afternoon after Vincent
dropped Sophia at the airport ¦ we’ ve been drinking really heavily since then ¦ we haven’ t
really done much else, or had much to eatOnset (from Johnny) œ¦we’ ve been pretty relaxed
all weekend, but he (Vincent) just seemed to really vague out (lose consciousness) about 10
minutes after we (equally) shared a hit (needle) of heroin ¦ that was about an hour
agoVincent’ s current medications (from Sophia) Ceftriaxone (recently administered by
GP), fluoxetine, olanzapine, peginterferon alfa-2a, ribavirin, diazepam, thiamine. Question 2
“ On the basis of Vincent’ s list of current medication, prior to undertaking any further
intervention: What risk factors can you identify that are relevant to the safety of yourself,
your partner and Johnny? What action(s) will you take on the basis of these considerations?
(5 marks) Question 3 “ Assuming that Vincent is an alcoholic but has no predisposing co-
morbidities, discuss the possible reasons why Vincent is more affected than Johnny, noting:

2. Interactions with Vincent’ s current medications. The potential impact of Vincent’ s
alcoholism. Potential recent changes to Vincent’ s lifestyle or drug use habits. (7.5 Marks)
After consultation with your partner, you set up an IV drip with 0.9% saline and administer
naloxone to Vincent following the Clinical Practice Guidelines of the Ambulance Service you
are working for. Question 4 “ Describe the mechanism by which an opioid agonist (such as
heroin) causes respiratory depression. In your response, consider the: Molecular
mechanism of action of opioid agonists. Pathophysiology of opioid-induced respiratory
depression. (7.5 Marks) Question 5 “ Discuss in detail: The pharmacodynamic rationale for
administering naloxone. The mechanism of action of naloxone. The pharmacological
considerations of current approaches to narcotic overdose recommending; Partial reversal
Rapid, full reversal (In your answer consider concepts related to the time course of the
treatment, the possible need to re-administer etc.) (10 Marks) Within 5 minutes, Vincent
becomes more lucid, and you undertake a further physical examination, which reveals:
Blood pressure 94/60mmHg Pulse 90 beats/min, regular Respiration 10 breaths/min
Oxygen saturation 99% (on 100% oxygen) Initially Vincent is very confused, but as he
becomes more conscious it soon becomes apparent that he does not want to go to hospital.
Question 6 “ Discuss your considerations regarding whether it is safe to leave Vincent in his
home? In your response consider: The likely pharmacological impact of Vincent’ s drug use.
The potential need for further medical treatment and or tests. (2.5 Marks) Drug Profile
activities for Module 5 Section 1: Life stages as a factor in variability 17. For your drug: a.
Determine whether dose adjustment is required for age and indicate the change in dosage
(e.g. higher or lower in young or elderly etc). b. Explain the rational for the age related dose
adjustment (or lack of dose adjustment) for your drug. Section 2: Impact of disease states
18. For your drug: a. Based on your knowledge of the pharmacokinetics of your drug, is dose
adjustment required in individuals with hepatic disease (explain)?