emergency management of drug overdose russell sharpswain, do, facep, faaem december 3, 2015
TRANSCRIPT
Emergency Management of
Drug Overdose
Russell Sharpswain, DO, FACEP, FAAEMDecember 3, 2015
Disclosures
• I have no financial connections or relationships to disclose.
Objectives• Understand current state of drug abuse in the
US• Assessment and initial management of the
patient with suspected drug overdose• Specific presentation and management of the
patient with abuse/overdose of:– Opiates – heroin and prescription pain pills– Marijuana and K2/Spice/synthetic cannabinoids– Stimulants – cocaine and methamphetamine– Hallucinogens – Ecstasy and Mushrooms
Objectives• Making an appropriate disposition on the drug
overdose patient
Drug Abuse…Statistics
• Drug use is on the rise…– 2013 = 9.4% – 2002 = 8.3%
• Mostly driven by increased use of marijuana, while other drugs have held steady
Drug Abuse…Statistics
Drug Overdose – ED Stats
• ED Statistics
Drug Overdose…Statistics
Drug Overdose…Statistics
Drug Overdose…Statistics
Drug Overdose…Statistics
• Most synthetic drug users and abusers under 25 years old
• Many of the synthetic or designer drugs are not easily detected on most ED drug screens
• Many synthetic drugs were readily available until July 2012 when law was passed banning all non-medical synthetic drugs including K2/Spice and “bath salts”
Drug Overdose• Chief complaints can vary widely– Altered mental status• Anxiety• Psychosis
– Nausea and vomiting– Palpitations/chest pain– Dyspnea– Diaphoresis
Drug Overdose• History– HPI = History of present illness• Environment• Witnesses • EMS report• Patient – if possible = Review of systems
– Past medical history
Drug Overdose
• Exam – PRIMARY ASSESSMENT– Vitals– Mental status– Airway– Breathing– Circulation
Drug Overdose• PRIMARY ASSESSMENT– A – Airway• GCS?
– B – Breathing• Respiratory rate
– C – Circulation• Pulses• Rate• Rhythm
Drug Overdose• Assessment and Stabilization– Cardiac monitoring– Continuous oximetry– IV fluids– Close observation
Drug Overdose
• Exam – SECONDARY ASSESSMENT– HEENT– Neck– Chest– Abdomen– Extremities– Skin– Neuro– Psych
Drug Overdose• Emergency Department ASSESSMENT– EKG– Labs• Baseline labs• Drug testing – DON’T BE FOOLED!• Special considerations
– Radiology• X-ray• CT
Drug Overdose• Emergency Department REASSESSMENT
• CANNOT UNDERESTIMATE THE IMPORTANCE OF REASSESSMENT IN THE DRUG OVERDOSE PATIENT!!!
OPIATES
• Heroin• Morphine• Hydromorphone (Dilaudid)• Fentanyl• Hydrocodone (Norco, Vicodin)• Oxycodone (Percocet, Oxycontin)• Codeine• Methadone and Suboxone
OPIATES…Clinical Use
• Pain relief
• Anti-tussive
• Decreased bowel motility
OPIATES…Overdose• Decreased level of consciousness
• Decreased respiratory rate
• Decreased tidal volume
• Decreased bowel sounds
• Miosis (constricted pupils)
• Lesser: urinary retention, urticaria, vomiting,
orthostatic hypotension
Opiate Overdose
• Immediate Treatment:
– AIRWAY
– BREATHING
– CIRCULATION
Opiate Overdose…Treatment• NALOXONE (Narcan)
– Opioid antagonist
– Can be given IV, IM, SQ, Neb, ETT
– Dose from 0.05mg to 2mg depending on clinical
situation
• ARREST: 2mg IV
• Others: 0.05mg to 0.2mg, titrate to effect
Opiate Overdose…Treatment
• NALOXONE (Narcan)
• GOAL: improve respiratory status, not level of
consciousness!
• Overshooting goal with Naloxone can cause
precipitous opioid withdrawal
Opiate Overdose
• Opioid Withdrawal
– Anxiety and Agitation
– Diaphoresis
– Myalgias
– Abdominal cramping
– Nausea and vomiting
– Lesser: Piloerection, yawning, mydriasis, insomnia
Marijuana
• Active ingredient: Delta-9-tetrahydrocannabinol• Can be smoked or ingested• Most commonly used illicit drug in US and Europe
Marijuana
• Symptoms– Impairment of attention and short-term memory, as
well as judgment of time and distance– Conjunctival injection– Increased appetite– Dry mouth– Tachycardia
K2 / Spice
• Synthetic marijuana– Also called Bliss, Black Mamba, Genie, Skunk,
Moon Rocks, and Zohai• In December 2011, National Institute on Drug
Abuse reported 1 in 9 high school students had used K2, making it the 2nd most abused drug by high schoolers
K2 / Spice
• Collection of plants/herbs sprayed with synthetic compound similar to THC – Resembles potpourri– Marketed as “incense you can smoke”
• Readily available until July 2012 when President signed bill making synthetic drugs including K2 illegal
K2 / Spice
• Symptoms– Agitation and anxiety– Tachycardia, chest pain, palpitations– Nausea and vomiting– Diaphoresis, pallor– Seizure / tremors– Paranoia, delusions
K2 / Spice
• Symptoms– Onset 3-5 minutes– Duration 1-8 hours
• Long term effects = Unknown
K2 / Spice
• Assessment– Cardiac monitoring and oximetry– EKG– Labs (as needed)• EtOH or drug screen
– DOES NOT SHOW UP ON STANDARD DRUG SCREEN
• Electrolytes
K2 / Spice
• Treatment = Symptomatic Support– IVF– Anti-emetics– Benzodiazepines– Anti-psychotics
• Disposition– Observe until symptom improvement
Stimulants (sympathomimetics)
• Cocaine• Amphetamine and methamphetamine• Mephedrone = “bath salts”• Ephedrine• Prescription drugs for ADHD, narcolepsy
Stimulants (sympathomimetics)
• Symptoms - Lethal– Signs of poisoning within 2 hours of exposure– Life threatening complications in 2-6 hours– Hypertension (and sequelae)– Cardiac arrhythmia or ischemia/infarction– Hyperthermia– Seizures or strokes
Stimulants (sympathomimetics)
• Symptoms – Non-lethal– Mydriasis– Tachycardia– Diaphoresis– Psychosis, delirium, paranoia– Bruxism
Stimulants (sympathomimetics)• Assessment– Vital signs• Core body temperature
– EKG and cardiac monitoring– Labs: BMP• Total CK• Drug screen• Other treatable ingestions
Stimulants (sympathomimetics)
• Treatment– PRE-HOSPITAL: Manage airway and control
agitation, blood glucose– ED: Symptomatic Support– Recognize and treat:• Hypoglycemia• Cardiac arrhythmia• Seizures
Stimulants
• Treatment– IVF– Benzodiazepines– Ketamine– Avoid physical restraints if possible– HTN – nitroprusside or nitroglycerin
Ecstasy
• MDMA = 3-4 methylenedioxymethamphetamine• Molly, Adam, E, Roll, X, XTC• Synthetic drug with hallucinogenic and stimulant
properties
Ecstasy
• Usually in pill form, often branded• Often mixed with many other drugs (ketamine,
ephedrine, methamphetamine, dextromethorphan, caffeine, and cocaine)
Ecstasy
• Younger people using at raves, parties, and concerts to “enhance senses”
• Peak use in 2000/2001– Decreased use overall, but recent studies show
increased use in 8th and 10th graders
Ecstasy
• Effects– Intensely pleasurable feelings and sensations– Enhanced self-confidence and energy– Peacefulness, acceptance, empathy– Feelings of closeness and desire to touch others
Ecstasy• Symptoms– Nausea and vomiting– Diaphoresis, blurred vision– Palpitations, tachycardia, hypertension – Teeth clenching, seizures, muscle cramps– Anxiety, depression, confusion– Dehydration, renal or hepatic dysfunction
Ecstasy
• Long-term effects– Disrupt metabolism and temperature regulation– Renal, liver, and cardiovascular failure– Problems with learning and memory– Rate of addiction 43%
Ecstasy• Assessment– Cardiac monitoring and oximetry– EKG– Body temperature– Labs as needed• Electrolytes, hepatic and renal function• EtOH• Drug screen
Ecstasy• Treatment = Symptomatic Support– IVF– Anti-emetics– Benzodiazepines– Anti-psychotics
Ecstasy• Treatment = REASSESSMENT– Hyperthermia– Mental status change– Cardiovascular stability
• Disposition– Home if symptoms improved and stable– Admit if unstable
Mushrooms
• Psychedelic mushrooms = “Magic mushrooms”– PSILOCYBIN causes hallucinations– Also known as shrooms, boomers, caps, Liberty
Cap, silly putty, Simple Simon• Grown in US, Mexico, UK, South America• Normally dried and eaten, but can be brewed
into a tea
Mushrooms
• Symptoms• Onset: 20 minutes• Duration: up to 6 hours– Hallucinations or distorted perceptions– Synesthesia– Intense fear or delusions– Changes in personality
Mushrooms
• Symptoms– Increased or decreased appetite– Nausea and vomiting– Dilated pupils– Tachycardia– Muscle relaxation or weakness, ataxia
• Long-term: flashbacks, psychosis, memory impairment, tolerance
Mushrooms
• Assessment– Cardiac monitoring and oximetry– EKG– Labs as needed based on symptoms– EtOH and drug screen
Mushrooms
• Treatment = Symptomatic Support– IVF– Anti-emetics– Benzodiazepines– Anti-psychotics– Quiet room with little sensory stimulation
Drug Overdose – Disposition?
• How do you know when it’s OK to send the patient with a drug overdose home?
Drug Overdose – Disposition?
• Opiates– No automatic need for prolonged observation or
admission after naloxone administration (CJEM, 2001)
Drug Overdose – Disposition?
• Normalization or Stabilization of vital signs• Resolution or Improvement of symptoms • Return to baseline mental status– If not returned to baseline mental status, sober
adult present to take responsibility for patient
Drug Overdose – Disposition?• Expected duration of drug effect has passed• If suspected to be intentional drug overdose,
psych assessment
Drug Overdose – Disposition?• Have to use clinical and ethical judgment in
some cases, as there is no clear black and white answer about who can safely go home, and who needs further observation
Drug Overdose - Summary
• Abuse of opiates and synthetic drugs is a growing problem in the US and around the world
• Principles of managing most drug overdose cases are similar regardless of what drug is causing symptoms
• Most synthetic drugs do not show up on routine drug screens
Drug Overdose - Summary
• Many drug overdose cases involve multiple different drugs, intentionally or otherwise
• Reassessment during observation of the drug overdose patient is very important
• The best treatment is often symptomatic care• Use sound clinical judgment when deciding
the disposition of the drug overdose patient
And always remember…
Drug Overdose
• Questions?
References• Tintinalli JE, et al. Emergency Medicine: a comprehensive study guide. 5th
Ed. 2000.• www.uptodate.com. Opioid intoxication in adults. 1/10/10.• Emergency Medicine Practice. Toxicology Update: a rational approach to
managing the poisoned patient. Volume 3 Number 8. August 2001.• K2 Drug Facts, online at http
://www.k2drugfacts.com/pdf/NewsPDF/ObamaSignsLegislation.pdf• The Partnership at Drugfree.org online at
http://www.drugfree.org/drug-guide/k2-spice and http://www.drugfree.org/drug-guide/ecstasy
• Businessinsider.com at http://www.businessinsider.com/15-maps-that-show-how-americans-use-drugs-2013-9
• http://mic.com/articles/80091/which-drug-is-your-state-most-addicted-to-this-map-reveals-a-disturbing-trend
References
• Traub SJ, Hoffman RS, Nelson LS. “The ‘ecstasy’ hangover: hyponatremia due to 3,4 – methylenedioxymethamphetamine.” Journal of Urban Health: Bulletin of the New York Academy of Medicine. Vol. 79. Dec 2002.
• Emedicine.com: Sympathomimetic toxicity at http://emedicine.medscape.com/article/818583-overview• Abovetheinfluence.com online at
http://www.abovetheinfluence.com/facts/drugsecstasy • National Institute on Drug Abuse online at
http://www.drugabuse.gov/publications/drugfacts/mdma- ecstasy and https://www.drugabuse.gov/related-topics/trends-statistics/overdose - death-rates and https://www.drugabuse.gov/publications/drugfacts / nationwide-trends• eMedicine through Medscape, Sympathomimetic toxicity, online at
http://emedicine.medscape.com/article/818583- overview• Mother Nature Network online at
http://www.mnn.com/family/protection-safety/stories/synthetic-marijuana-can-cause-unusual-side-effects-in-teens#