Toxicology: Street Drugs

1. 27 Toxicology: Street Drugs

2. Objectives • Discuss the frequency of abused drugs in the U.S. • Recognize how to recognize street drugs by assessment patterns. • Discuss assessment findings and management for a patient suffering from a street drug overdose.

3. Introduction • Drug use was, at one time, almost exclusive to large metro areas. • Drug use is now seen in rural areas and in all socioeconomic classes. • Mixing of illegal drugs has also gained popularity.

4. Epidemiology • The National Survey on Drug Use and Health (NSDUH) reports over 19.9 million Americans ages 12 and older used illegal drugs within the month of survey in 2007. • Highest bracket—18-20 year olds.

5. Epidemiology (cont’d) • Most commonly abused drugs in descending order: marijuana, psychotropics, cocaine, hallucinogens, inhalants, and heroin.

6. Pathophysiology (cont’d) • Too many drugs and drug names to possibly know them all.

7. Pathophysiology (cont’d) • Learn to recognize a “toxidrome,” which refers to how the drug is affecting the body. • Uppers • Downers • Narcotics • Mind-altering • Volatile chemicals

8. Commonly Abused Drugs

9. Pathophysiology (cont’d) • Stimulants • Profound effect on body that imitates the sympathetic nervous system. • HTN, tachycardia, pupil dilation, temp elevation, trembling. • Patient may experience a hypertensive crisis, an MI, or even seizures. • Patient may also be combative, aggressive, or delirious.

10. Pathophysiology (cont’d) • Depressants (narcotics and sedatives) • Lowering of bodily activities. • Brain stem depression. • HR drops, blood pressure drops, respirations drop. • Orientation diminishes, muscle tone goes lax. • Pupillary constriction common.

11. Pathophysiology (cont’d) • Cannabis products • Both psychological and physiological effects. • Changes in perception. • Mood swings. • Disturbed short-term memory. • Heart rate elevates, B/P drops.

12. Pathophysiology (cont’d) • Hallucinogens • Agents that change perceptions of reality. • Patient “hears” and “sees” things that are not part of reality. • Distortions to shapes, colors, sounds. • Hemodynamically they are usually stable, but mentally they have disturbances.

13. Pathophysiology (cont’d) • Inhalants • Volatile in nature, they are sniffed or inhaled. • Many agents are found in home products. • Damage may also occur to mucous membranes and lung tissue.

14. Pathophysiology (cont’d) • Inhalants • Many of these agents displace oxygen and the patient has confusion, coma, seizures, heart failure, or even pulmonary edema.

15. Pathophysiology (cont’d) • Alcohol • Brain is the first organ affected with ingestion. • Initial feeling of euphoria with subsequent depression and impairment of cognition and other abilities. • Great risk for vomiting and aspiration.

16. Assessment Findings • General considerations • Use dispatch information. • Always protect yourself from harm. • Clues at the scene may point to drug abuse. • Learn to recognize not the drug itself, but what toxidrome it fits into.

17. A variety of substances may be abused.

18. Emergency Medical Care • Ensure an open airway. • Provide supplemental oxygen. • Position the patient (consider blood pressure and potential for aspiration). • Determine blood glucose level.

19. Emergency Medical Care (cont’d) • Consider use of 1g/kg activated charcoal if situation is appropriate. • If narcotic (opioid) overdose is suspected, administer naloxone 0.4-2.0 mg titrated to respiratory effort. • Provide rapid transport to ED.

20. Case Study • You are called to a party where several underage teenagers were reportedly drinking and doing drugs (per neighbor who summoned PD and EMS). Upon your arrival, a patient is found unresponsive on the porch with gurgling respirations that are slow. PD is already on the scene.

21. Case Study (cont’d) • Scene Size-Up • Standard precautions taken. • 16–17-year-old male, normal weight. • No sign of struggle or trauma. • Patient lying supine, looks unresponsive. • NOI is “unknown medical.” • PD on scene, no additional resources needed.

22. Case Study (cont’d) • Primary Assessment Findings • Patient unconscious to noxious stimuli. • Gurgling sounds coming from airway. • Breathing is slow and shallow. • Carotid pulse feels slow, peripheral pulse absent. • No signs of bleeding or trauma. • No one on scene seems to “know” this person.

23. Case Study (cont’d) • Is this patient a high or low priority? • What life threats, if any, is this patient presenting with? • What interventions are warranted at this time?

24. Case Study (cont’d) • Medical History • Unknown • Medications • Unknown • Allergies • Unknown

25. Case Study (cont’d) • Pertinent Secondary Assessment Findings • Patient unresponsive to noxious stimuli. • Airway now clear, breathing slow at 6/min. • No alveolar breath sounds, no peripheral pulse. • Pulse oximeter reads 88% on room air.

26. Case Study (cont’d) • Pertinent Secondary Assessment Findings • Skin cool, dry, ashen in color. • B/P unobtainable, HR 122/min, RR 6/min. • Pupils pinpoint and nonreactive.

27. Case Study (cont’d) • What would be your differentials with this type of overdose? • What is your final differential for the type of toxidrome? • Relate the vital signs to the category of toxidrome.

28. Case Study (cont’d) • Care provided: • Spinal immobilization as a precaution. • High-flow oxygen via PPV @ 10/min. • Ongoing pulse oximeter reading and BGL testing. • Supine positioning. • Narcan administration

29. Summary • Drug abuse is still on the rise in many regions and profiles of individuals in the U.S. • So many drugs are now abused, the Advanced EMT may want to focus on recognizing the toxidrome itself, not the specific agent.

30. Summary (cont’d) • Management must be geared toward the toxidrome, and supportive of any lost bodily function.