1. Emergency Management of Drug Overdose
Russell Sharpswain, DO, FACEP, FAAEM
December 3, 2015

2. Disclosures
I have no financial connections or relationships to disclose.

3. 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

4. Objectives
Making an appropriate disposition on the drug overdose patient

10. 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

12. Drug Abuse…Statistics

14. Drug Overdose – ED Stats
ED Statistics

15. Drug Overdose…Statistics

16. Drug Overdose…Statistics

17. Drug Overdose…Statistics

18. 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”

19. Drug Overdose Chief complaints can vary widely Altered mental status
Anxiety
Psychosis
Nausea and vomiting
Palpitations/chest pain
Dyspnea
Diaphoresis

20. Drug Overdose History HPI = History of present illness
Environment
Witnesses
EMS report
Patient – if possible = Review of systems
Past medical history

21. Drug Overdose Exam – PRIMARY ASSESSMENT Vitals Mental status Airway
Breathing
Circulation

22. Drug Overdose PRIMARY ASSESSMENT A – Airway B – Breathing
GCS?
B – Breathing
Respiratory rate
C – Circulation
Pulses
Rate
Rhythm

23. Drug Overdose Assessment and Stabilization Cardiac monitoring
Continuous oximetry
IV fluids
Close observation

24. Drug Overdose Exam – SECONDARY ASSESSMENT HEENT Neck Chest Abdomen
Extremities
Skin
Neuro
Psych

25. Drug Overdose Emergency Department ASSESSMENT EKG Labs Radiology
Baseline labs
Drug testing – DON’T BE FOOLED!
Special considerations
Radiology
X-ray CT

26. Drug Overdose Emergency Department REASSESSMENT
• CANNOT UNDERESTIMATE THE IMPORTANCE OF REASSESSMENT IN THE DRUG OVERDOSE PATIENT!!!

27. OPIATES Heroin Morphine Hydromorphone (Dilaudid) Fentanyl
Hydrocodone (Norco, Vicodin)
Oxycodone (Percocet, Oxycontin)
Codeine
Methadone and Suboxone

28. OPIATES…Clinical Use
Pain relief
Anti-tussive
Decreased bowel motility

29. 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

30. Opiate Overdose
Immediate Treatment:
AIRWAY
BREATHING
CIRCULATION

31. 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

32. Opiate Overdose…Treatment
NALOXONE (Narcan)
GOAL: improve respiratory status, not level of consciousness!
Overshooting goal with Naloxone can cause precipitous opioid withdrawal

33. Opiate Overdose Opioid Withdrawal Anxiety and Agitation Diaphoresis
Myalgias
Abdominal cramping
Nausea and vomiting
Lesser: Piloerection, yawning, mydriasis, insomnia

34. Marijuana Active ingredient: Delta-9-tetrahydrocannabinol
Can be smoked or ingested
Most commonly used illicit drug in US and Europe

35. Marijuana
Symptoms
Impairment of attention and short-term memory, as well as judgment of time and distance
Conjunctival injection
Increased appetite
Dry mouth
Tachycardia

36. 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

37. 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 when President signed bill making synthetic drugs including K2 illegal

38. K2 / Spice Symptoms Agitation and anxiety
Tachycardia, chest pain, palpitations
Nausea and vomiting
Diaphoresis, pallor
Seizure / tremors
Paranoia, delusions

39. K2 / Spice Symptoms Long term effects = Unknown Onset 3-5 minutes
Duration 1-8 hours
Long term effects = Unknown

40. K2 / Spice Assessment Cardiac monitoring and oximetry EKG
Labs (as needed)
EtOH or drug screen
DOES NOT SHOW UP ON STANDARD DRUG SCREEN
Electrolytes

41. K2 / Spice Treatment = Symptomatic Support Disposition IVF
Anti-emetics
Benzodiazepines
Anti-psychotics
Disposition
Observe until symptom improvement

42. Stimulants (sympathomimetics)
Cocaine
Amphetamine and methamphetamine
Mephedrone = “bath salts”
Ephedrine
Prescription drugs for ADHD, narcolepsy

43. 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

44. Stimulants (sympathomimetics)
Symptoms – Non-lethal
Mydriasis
Tachycardia
Diaphoresis
Psychosis, delirium, paranoia
Bruxism

45. Stimulants (sympathomimetics)
Assessment
Vital signs
Core body temperature
EKG and cardiac monitoring
Labs: BMP
Total CK
Drug screen
Other treatable ingestions

46. Stimulants (sympathomimetics)
Treatment
PRE-HOSPITAL: Manage airway and control agitation, blood glucose
ED: Symptomatic Support
Recognize and treat:
Hypoglycemia
Cardiac arrhythmia
Seizures

47. Stimulants Treatment IVF Benzodiazepines Ketamine
Avoid physical restraints if possible
HTN – nitroprusside or nitroglycerin

48. Ecstasy MDMA = 3-4 methylenedioxymethamphetamine
Molly, Adam, E, Roll, X, XTC
Synthetic drug with hallucinogenic and stimulant properties

49. Ecstasy Usually in pill form, often branded
Often mixed with many other drugs (ketamine, ephedrine, methamphetamine, dextromethorphan, caffeine, and cocaine)

50. 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

51. Ecstasy Effects Intensely pleasurable feelings and sensations
Enhanced self-confidence and energy
Peacefulness, acceptance, empathy
Feelings of closeness and desire to touch others

52. Ecstasy Symptoms Nausea and vomiting Diaphoresis, blurred vision
Palpitations, tachycardia, hypertension
Teeth clenching, seizures, muscle cramps
Anxiety, depression, confusion
Dehydration, renal or hepatic dysfunction

53. Ecstasy Long-term effects
Disrupt metabolism and temperature regulation
Renal, liver, and cardiovascular failure
Problems with learning and memory
Rate of addiction 43%

54. Ecstasy Assessment Cardiac monitoring and oximetry EKG
Body temperature
Labs as needed
Electrolytes, hepatic and renal function
EtOH
Drug screen

55. Ecstasy Treatment = Symptomatic Support IVF Anti-emetics
Benzodiazepines
Anti-psychotics

56. Ecstasy Treatment = REASSESSMENT Disposition Hyperthermia
Mental status change
Cardiovascular stability
Disposition
Home if symptoms improved and stable
Admit if unstable

57. 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

58. Mushrooms Symptoms Onset: 20 minutes Duration: up to 6 hours
Hallucinations or distorted perceptions
Synesthesia
Intense fear or delusions
Changes in personality

59. Mushrooms
Symptoms
Increased or decreased appetite
Nausea and vomiting
Dilated pupils
Tachycardia
Muscle relaxation or weakness, ataxia
Long-term: flashbacks, psychosis, memory impairment, tolerance

60. Mushrooms Assessment Cardiac monitoring and oximetry EKG
Labs as needed based on symptoms
EtOH and drug screen

61. Mushrooms Treatment = Symptomatic Support IVF Anti-emetics
Benzodiazepines
Anti-psychotics
Quiet room with little sensory stimulation

62. Drug Overdose – Disposition?
How do you know when it’s OK to send the patient with a drug overdose home?

63. Drug Overdose – Disposition?
Opiates
No automatic need for prolonged observation or admission after naloxone administration (CJEM, 2001)

64. 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

65. Drug Overdose – Disposition?
Expected duration of drug effect has passed
If suspected to be intentional drug overdose, psych assessment

66. 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

67. 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

68. 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

69. And always remember…

70. Drug Overdose
Questions?

71. References
Tintinalli JE, et al. Emergency Medicine: a comprehensive study guide. 5th Ed
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
The Partnership at Drugfree.org online at and
Businessinsider.com at

72. 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
Abovetheinfluence.com online at
National Institute on Drug Abuse online at
and
death-rates and
nationwide-trends
eMedicine through Medscape, Sympathomimetic toxicity, online at
Mother Nature Network online at