Emergency management of person with drug use.

2. Emergencies related to
substance use and its
management

3. Objectives
• To identify the patient of substance use
• To manage/to help in managing the patient in ER

4. • Every 10 seconds a person dies from alcohol-
related causes including cancer, heart disease,
traffic accident and violence
• Results in 3.3 million deaths/year
• 275 million people used illicit drugs, (cannabis,
amphetamines, opioids, and cocaine)
• 31 million of people who use drugs suffer from
drug use disorders

5. • Intoxication:
• onset of specific syndromes related to the recent intake
of (or exposure to) substances.
• abnormal functioning of the CNS and of other systems.
• T/t- stopping or reducing the acute effects of the
substance.

6. • Symptoms of drug intoxication or withdrawal may
present in atypical ways (modality of use,
combination of drugs used, purity of the substance
used, and characteristics of individual drugs).
• Co-existing disease
• Mental health disorders: mood disorders, anxiety
disorders, personality disorders, and schizophrenia.

7. Guidelines for the treatment of SUD
• Intense intoxication:
• reducing exposure to external stimuli.
• providing confidence, guidance, and reality testing in a
safe and monitored environment.
• Investigate:
• which substances
• routes of administration
• doses
• time since the last dose
• whether the intoxication level is increasing or decreasing

8. Guidelines for the treatment of SUD
• Removing the substance from the body
• Reversing the effects of the substance with the
administration of antagonists
• Stabilizing the physical effects of the overdose

9. ABC

10. • Drug intoxication
• Drug withdrawal

11. Benzodiazepines
• Lorazepam, Alprazolam, Diazepam, Clonazepam,
Temazepam,Fflurazepam.
• Features:
• drowsy
• unsteady
• confused
• disoriented
• less alert
• Impaired judgment

12. Benzodiazepines
• CNS depressors with acute intoxication effects
(similar to alcohol).
• Risk of respiratory depression.
• Hypotension and bradycardia, (more pronounced
when associated with other substances).
• Excessive intake of benzodiazepines alone rarely
induces deep coma and death.
• long-acting compound (clonazepam), the clinical
signs of intoxication can continue for 24 hours.

13. Benzodiazepines
• Antidote:
• Flumazenile-
• Specific benzodiazepine antagonist (neurological or
respiratory depression).
• Contraindicated- TCA, aminophylline, and cocaine.

14. Benzodiazepines Withdrawal
• Related to the sudden discontinuation in the use of
these substances.
• Risk factors: prolonged use of high doses.
• Features:
• anxiety, insomnia, headaches, anorexia, nausea,
vomiting, tremor, orthostatic hypotension, and
weakness may appear between 1 and 11 days after
withdrawal.

15. Benzodiazepines Withdrawal
• Discontinuation:
• Short-acting- withdrawal symptoms within a few hours
• Long-acting- delayed until the following day or even
later

16. Benzodiazepines Withdrawal
• Phenobarbital: 30mg equivalent to 10mg of
diazepam, 30mg of chlordiazepoxide, 1mg of
lorazepam, and 1mg of alprazolam.
• After stabilization, progressive reduction is
recommended in the daily rate of 10% of the initial
dose.

17. Marijuana
• Acute effect/High dose:
• Psychotic symptoms and acute anxiety episodes
resembling panic attacks (reasons to seek treatment)
• T/t: primarily based on benzodiazepines (oral).
• Intoxication:
• aggressive behaviors, (due to the distorted perception of
reality)
• T/t: same as in cocaine users.

18. Marijuana Withdrawal
• Symptoms:
• irritability, appetite alterations, weight loss, and physical
discomfort.
• No specific pharmacological treatment.

19. Alcohol
• Effects vary according to the level of consumption
• Low dose: mild euphoria and uninhibited behavior
• Substantial dose: may trigger irrational thinking,
problematic behavior, psychomotor difficulties, and
coma (rare cases).

20. Alcohol
Blood alcohol
level
Clinical Features
20 - 40 mg% Impaired muscle coordination, mood and
behavioral alterations, and increased motor activity
80 – 200 mg% Progressive neurological alterations, including
ataxia and slurred speech. Impaired cognitive
function.
>300mg% Hypothermia and impaired level of consciousness
400 - 600mg% Coma
600-800mg% Usually fatal- (failure of respiratory, cardiovascular,
and body temperature control)

21. Alcohol
• Blood alcohol levels >150mg%:
• Vitals monitoring in a quiet and safe environment,
and the patient’s airways protected.
• IVF (Normal Saline).
• Hypertonic glucose (only in hypoglycaemia).
• Thiamine- to avoid the risk of Wernicke’s
encephalopathy

22. Alcohol
• Alcohol: not absorbed by activated carbon and
therefore its use is not indicated.
• Elimination: 10-30mg% per hour.
• Preserve the respiratory and cardiovascular
functions until alcohol levels in the blood are within
a safe range.
• Monitoring of vital functions, preserving respiration
and avoiding the aspiration of gastric contents,
hypoglycemia, and thiamine deficiency.

23. Alcohol
Agitation:
• Better managed by using interpersonal and nursing
approaches instead of additional medication (which
may complicate and delay the elimination of
alcohol).

24. Alcohol Withdrawal
• Symptoms-
• Generally begin within 4-12 hours after use cessation or
reduction.
• Intensity reaches its peak on the 2nd day and ends in 4 –
5 days.
• Tremors, GI discomfort, anxiety, irritability, elevated BP,
tachycardia, and overactivity of the autonomic system,
seizures, hallucinations, and delirium.

25. Alcohol Withdrawal
• Treatment:
• Thiamine (50mg diluted in 100ml of NS and infused for
30 minutes, three times a day, for 2 -3 days.)
• Maintenance of the water balance
• Benzodiazepines (chlordiazepoxide, diazepam and
lorazepam)
• Anticonvulsants
• Clonidine
• Antipsychotics

26. Alcohol Withdrawal
• Wernicke’s encephalopathy:
• Clinically diagnosed and its existence should be
considered in cases of nutritional deficiency, nystagmus,
ataxia, and mental state alterations.
• Acute thiamine deficiency
• Small fraction of cases (around 15%) are identified
before death
• Thiamine should be administered prior to or during the
administration of glucose.

27. Alcohol Withdrawal
• Delirium Tremens:
• Up to 72 hours after of the last dose
• May last from 2 - 10 days
• Alterations in the level of consciousness,
depersonalization, and dysphoric mood, oscillating
between apathy and intense agitation and even
aggressiveness.
• Tonic-clonic seizures

28. Cocaine and Amphetamines
• Intoxication:
• Restlessness, anxiety, hyperactivity, euphoria, dysphoria,
increased BP, HR and RR.
• Hallucinations and paranoid delusions.
• Can be potentiated by alcohol
• Cardiac arrhythmias and extremely elevated BP (may be
life-threatening).
• Hyperthermia, brain hemorrhage, seizures, respiratory
insufficiency, and cardiac insufficiency.
• Intoxication is usually self-limited and requires only
monitoring and support interventions.

29. Cocaine
• Extremely intense psychomotor agitation,
hyperthermia, aggressiveness, and hostility have
been reported “excited delirium”.
• Risk of death
• Must receive intensive care.
• T/t: benzodiazepines / neuroleptics
• IM/IV- intense psychomotor agitation and
aggressiveness.

30. Cocaine
• Precordial pain may be associated with acute
myocardial infarction (AMI)
• ECG, CBC, LFT, RFT, electrolytes, and creatine
phosphokinase-MB.
• Treated as regular cases of ACUTE CORONARY
SYNDROME.

31. Amphetamines
Intoxication:
• decreased appetite, increased stamina and physical
energy, irritability, aggressiveness, psychotic
features, increased sexual drive, involuntary bodily
movements, increased perspiration, hyperactivity,
jitteriness, nausea, increased and irregular heart
rate, and rarely, seizure.

32. Amphetamines
• Intake of high doses of amphetamines may require
gastric lavage and activated carbon (around 30
minutes).
• Presence of hypertension, seizures, and
persecutory delusions in some patients who use
stimulants may require specific treatment.

33. Cocaine and Amphetamine Withdrawal
• 3 phases:
• 1st phase: few hours up to five days. Intense craving in
the beginning, irritability, and agitation, evolving with
hypersomnolence, depression, anhedonia, and
exhaustion, followed by a reduction in craving.
• 2nd phase: relapse of craving and with depression and
anxiety symptoms, lasting up to 10 weeks.
• 3rd phase: gradual reduction in craving and the tendency
to normalize mood, sleep, and anxiety.
• Pharmacological treatments are rarely beneficial in
the management of cocaine withdrawal symptoms.

34. Opioids
• Euphoric effects of opioids contribute to their
widespread abuse. (Heroin, morphine, codeine,
oxycodone, and fentanyl)
• Signs of intoxication:
• Sedation, psychomotor difficulties, confusion, pinpoint
pupils and, in more extreme cases, respiratory
depression.

35. Opioids
• Intoxication:
• mild to moderate cases- specific treatment is usually not
necessary.
• Overdose:
• myosis and bradycardia, respiratory depression, stupor,
or coma.
• Hospitalization and support ventilation

36. Opioids
• Long half-life opioids (methadone) require greater
attention.
• Observe for 24 - 48 hours (respiratory depression-
can be fatal)
• Naloxone:
• 0.05-0.4 mg IV
• Lower doses are used in patients addicted to opioids
(risk of severe withdrawal syndrome)

37. Opioids Withdrawal
• On discontinuation, the withdrawal usually appears
within a few hours for most of the drugs in this
class and may last up to 1 week.
• Signs and symptoms (most common)
• diarrhea, abdominal cramping, generalized pain,
piloerection, and rhinorrhea.
• Withdrawal- usually very uncomfortable, it is not
life-threatening

38. Opioids Withdrawal

39. Opioids Withdrawal
• Mydriasis, increased SBP, increased PR, sweating,
chills, yawning, pain throughout the body, diarrhea,
rhinorrhea, and tears.
• Methadone-
• maintenance of methadone replacement is not
recommended outside of the hospital environment.

40. Opioids Withdrawal
Clonidine:
• 2nd line indication
• 0.1-0.3mg divided in three doses
• Contraindicated: recent history of CVA or heart
disease

41. Summary
• Maintain the Airway, Breathing and Circulation.
• Control the symptoms of drug overdose or
withdrawal

42. THANK YOU