0. International Trauma Life Support, 7e
Patients Under the Influence of Alcohol or Drugs 20
Key Lecture Points
Review commonly abused drugs and their common signs and symptoms.
Review clues of drug use by the patient.
Review the pertinent history you should obtain when managing a patient who may be under the influence of drugs.
Explain how to interact with a patient who is under the influence of drugs.
Explain how to manage the patient who is injured, under the influence, and uncooperative. Be familiar with and discuss your local laws regarding restraining a patient.

1. Patients Under the Influence
Courtesy of Louis B. Mallory, MBA, REMT-P

2. Overview Signs and symptoms of under influence of alcohol and/or drugs
Five strategies to ensure cooperation
Situations to restrain patients and how to handle an uncooperative patient
Special considerations for assessment and management with substance abuse

3. Under Influence Trauma and alcohol or drugs
Car crashes involving alcohol
Substance abusers at greater risk of injury
High rate of alcohol and drug use in fatalities
Suspicion of alcohol or drug influence
Use high index of suspicion, physical exam, history, bystanders, evidence at scene to identify
NOTE: Substance abuse includes abuse of alcohol, drugs, or both.
Substance abuse is associated with a number of traumatic events, often resulting from accidents, car crashes, suicides, homicides, and other violent crimes.
One study found a high rate of alcohol and illicit drug use in patients who die from trauma (Journal of American College of Surgeons).
Number of seriously injured trauma patients are under influence of alcohol or some other substance.
History supplied by the patient or bystanders can also help to establish whether substance abuse is involved. Obtain history from patient and bystanders, but remember many patients (and bystanders) deny substance use.
If possible, inspect patient's surroundings for clues that drugs or alcohol may have been used. Note any alcoholic beverage bottles, pill containers, injection equipment, smoking paraphernalia, or unusual odors.

4. Patients Under Influence
Unique challenges for management
Under the influence vs. an emergency
May need to alter management techniques
Many initially refuse treatment
Interaction and cooperation
Consult local protocol, medical direction, and law enforcement for assistance
It is extremely difficult to differentiate between patients under the influence and those experiencing a medical and/or trauma emergency.

5. Assessment ITLS Primary and Secondary Surveys Note: Mental status
Respiration
Speech
Pupils
Needle marks
IMAGE: Needle marks.
NOTE: Other items in list covered on next slides.
ITLS Primary and Secondary Surveys should follow the ITLS guidelines.
These are particular aspects to be aware of when conducting the exam when you suspect the patient has abused substances.
© Pearson

6. Mental Status Altered mental status Euphoria Psychosis Paranoia
Confusion
Disorientation
Due to head injury, shock, hypoglycemia until proven otherwise
Remember that altered level of consciousness is always due to a head injury, shock, or hypoglycemia, until proven otherwise.
An altered mental status can be seen in every form of substance abuse.
Courtesy of Louis B. Mallory, MBA, REMT-P

7. Under Influence Respirations Speech Significantly depressed Slurred
Opiates and sedatives
Speech
Slurred
Alcohol or sedatives
Ramble
Hallucinogens
Courtesy of Louis B. Mallory, MBA, REMT-P

8. Pupils Constricted Dilated Fixed and dilated Opiates
Early barbiturate use
Dilated
Amphetamines
Cocaine
Hallucinogens
Marijuana
Fixed and dilated
High-dose barbiturates
Courtesy of Louis B. Mallory, MBA, REMT-P

9. Commonly Abused Drugs
IMAGE: Table 20-1 Commonly Abused Drugs.

10. Interaction Interaction style influences cooperation
Offensive and judgmental
Can cause patients to be uncooperative
Can lengthen on-scene time
Positive and nonjudgmental
Can cause patients to be cooperative
Easier assessment with all appropriate interventions
Trauma patients under the influence of alcohol or drugs can challenge the provider not only by their traumatic injuries, but also by their attitudes.
The way in which you interact with patients who have abused substances can determine if the patient will be cooperative or uncooperative.
How you speak to these patients can be as important as what you are doing for them.

11. Interaction Strategies
Improving cooperation
Identify yourself and orient patient to surroundings
Treat with respect and avoid being judgmental
Acknowledge concerns and feelings
Let patients know what will be required of them
Ask closed-ended questions for history
Ask them their name and how they would like to be addressed. With this patient population, it may be necessary to orient them to place, date, and what is going on. These patients may need to be reoriented frequently.
Often, a lack of respect can be heard in tone of your voice or how you say things, not just in what you say.
The patient who is scared or confused may be more comfortable with what is taking place if you recognize and address these feelings. Be gentle but firm. Explain all treatment interventions before they are performed.
Patients may be confused and not realize that they need to hold still while you are trying to stabilize them on a backboard.
Closed-ended questions are questions that can be answered with a yes or no. These patients may only be able to concentrate for short periods of time, and they may ramble when asked open-ended questions that require a full answer. Consider getting as much of history as you can from relatives, friends, or bystanders.

12. Uncooperative Patient
Interacting with uncooperative patients:
Be firm
Set limits to behavior
Consider physical restraint
Only if unable to provide adequate care
Show of force may be enough

13. Restraints Know local protocols Law enforcement Threat to self
Types of restraints
Spinal immobilization
Reeves sleeve
Soft restraints
Chemical
In some circumstances, chemical restraints may be required.
Know requirements in local jurisdiction for restraining patients against their will. Know who can restrain, under what conditions a patient can be restrained, and what types of devices can be used, like soft restraints.
Securely strapping a patient to a backboard with use of a cervical collar and head motion-restriction device will serve to restrain most patients.
Caution must be taken not to worsen any current injuries or inflict any new ones.
Restrained patients may struggle so hard that spinal motion restriction is rendered ineffective.
Reeves sleeve is one of the few pieces of equipment that is very effective in providing both restraint and motion restriction.
Crews should plan and practice procedures for restraining patients.
Reassess restrained patients often.
© Pearson

14. Patients Under Influence
ITLS Primary and Secondary Surveys
Note:
High risk for infection
Look for clues to substance abuse
Finger-stick glucose for altered mental status
Cardiac monitoring for altered mental status
High-flow oxygen and capnography
Hypothermia and hypotension common
ITLS approach to patient care will work well, even with patients under the influence of alcohol or drugs.
This patient population includes people who are at high risk for infection with hepatitis B, hepatitis C, and HIV.

15. Specific Treatments
IMAGE: Table 20-2 Drug Categories and Specific Treatments to Consider.
*Naloxone should be titrated to patient's respirations. Repeated doses may be indicated as narcotic may last longer than effects of naloxone.
**Flumazenil use is controversial; it can precipitate seizures in patients dependent on benzodiazepines. Further, flumazenil use may cause seizures in those who have been using benzodiazepines to prevent seizures and in those patients who have overdosed on tricyclic antidepressants. Flumazenil should only be given on direct order of medical direction.

16. NIDA 2009 USA Study Teenage drug use decreasing
Belief MDMA (ecstasy) not harmful
Concerned with nonmedical use of:
Hydrocodone (Vicodin)
Oxycodone (OxyContin)
Based upon a 2009 survey of teenagers, The National Institute on Drug Abuse (NIDA) concluded that many drug use trends are declining.
However, they reported that the perception that the Methylenedioxymethamphetamie MDMA (ecstasy) is harmful is going down and this might be a precursor to an increase in use of this drug.
The NIDA also expressed concern about the nonmedical use of the narcotics Vicodin (hydrocodone) and OxyContin (oxycodone).

17. Summary Know signs and symptoms of abuse:
Recognize patient who may be impaired
Attention to specific areas for critical changes
Provide lifesaving interventions for substances
Interaction strategies for improving patient cooperation are very important
Safety is primary concern
People who abuse alcohol and drugs are frequently involved in trauma. Be prepared to treat them often.
Determining that your patient has abused some substance will allow you to pay attention to specific areas for critical changes as well as provide lifesaving interventions that may be indicated for individual substances.
If you must restrain a patient for his or her safety, do so in a preplanned manner that is most sensitive to your patient's needs.