9.5. POISONING/OVERDOSE BY STIMULANTS

Related titles

Stimulant, cocaine, methamphetamine, amphetamines, phencyclidine, bath salts.

Purpose of assistance

1. Recognize toxic substances.
2. Protect such organs as the heart, brain, liver, kidneys from damage.
3. Determine if there is an antidote.
4. Treat symptoms, which may include tachycardia and hypertension, agitation, hallucinations, chest pain, seizures, and arrhythmia.

Description of the patient

Inclusion criteria

1. Tachycardia/tachyarrhythmia.
2. Hypertension.
3. Sweating.
4. Delirium/paranoia.
5. Convulsions.
6. Hyperthermia.
7. Mydriasis.
8. Stimulant and hallucinogenic drugs (with stimulating properties):

a) cocaine;
b) amphetamine/methamphetamine;
c) phencyclidine (hallucinogen);
d) bupropion;
e) synthetic stimulant drugs (some have mixed effects);
e) ecstasy;
e) methamphetamine;
e) synthetic cathinones (bath salts);
g) spice;
h) K2;
i) synthetic tetrahydrocannabinol;
i) cat.

Exclusion criteria

No recommendations.

Management of patients

Status assessment

1. Conduct an initial examination (ABCDE):

a) whether airways are open;
b) whether oxygenation is sufficient;
c) whether perfusion is sufficient;
d) state of consciousness;

br />e) treat any violations of these parameters;
e) ask about the presence of chest pain or difficulty breathing.

2. Vital signs.

3. Use a cardiac monitor and analyze for arrhythmias.

4. Check your glucose level.

5. Monitor ETSO2 to detect respiratory decompensation.

6. Record a 12-lead ECG (if possible).

7. Check for injuries or self-inflicted injuries.

8. Law enforcement must check for weapons and drugs, but you can choose to repeat the check.

Treatment and intervention

1. Provide IV access for infusion of fluids or drugs.

2. Administer solutions with poor perfusion; cold solutions for hyperthermia (see instructions “Shock” and “Hyperthermia/Influence of a warm environment”).

3. Treat chest pain like GCS and follow STEMI protocol.

4. Treat shortness of breath as an atypical manifestation of ACS.
Carry out oxygen therapy with a target saturation level of 94-98%.

5. Use gentle means of patient control, especially if law enforcement has been involved in calming the patient (see Aggressive or Aggressive Patient/Behavioral Emergency Management).

6. Use medications to calm hyperarousal and other severe sympathomimetic signs for the safety of the patient and EMD staff. This may improve behavior and adherence (see Agitated or Aggressive Patient/Behavioral Emergency Guideline).
When using haloperidol or droperidol, check the 12-lead ECG for interval changes QT.

7. Use antiemetic drugs for preventive purposes:

a) adults: ondasetron 8 mg IV SLOWLY over 2-5 minutes or 4-8 mg IV or 8 mg orally in the form of a soluble tablet;
b) children: ondansetron 0.15 mg/kg IV SLOWLY over 2-5 min;
c) do not use promethazine if you are going to administer or have already administered haloperidol or droperidol. All of them cause prolongation of the QT interval, however, ondansetron carries a lower risk of seizures.

8. If hyperthermia is suspected, start external cooling.

Patient safety

1. Use as few physical patient controls as possible to ensure the safety of yourself and the patient (see Agitated or Aggressive Patient/Behavioral Emergency Guideline).
2. Evaluating the potential presence of weapons or additional narcotics is very important, as these items pose a threat to both the patient and the EMD team.

Useful information for training

Key points

1. Recognition and treatment of hyperthermia ((including the use of sedatives to reduce heat production due to muscle activity) is important because many deaths are caused by overheating.

2. If the patient is handcuffed by law enforcement and must be restrained for safe transport, take one law enforcement officer with you in the carriage for the duration of the transport or change the handcuffs to other means of control before law enforcement officers leave the scene and you go to reception department.

3. If the patient has signs and symptoms of ACS, apply glyceryl trinitrate under the tongue at intervals of 3-5 minutes, provided that the systolic blood pressure is above 100 mmHg. and until the pain is relieved (if the level is not reached, apply every 3 minutes):

a) in this case, the problem of vasospasm is common, as opposed to permanent damage to the coronary artery;
b) use benzodiazepines in case of patient anxiety.

4. Providing IV access, monitoring cardiac rhythms, SPO2/ETCO2 are the keys to early detection and timely intervention for decompensatory mechanisms.
If the patient is agitated, consider patient restraints to facilitate patient assessment and reduce the likelihood of vascular IV displacement catheter or monitor.

5. Cocaine has sodium channel blocking effects and can cause significant cardiac conduction abnormalities with a widened QRS. Treatment with sodium bicarbonate is similar to treatment with a tricyclic antidepressant. Check for a 12-lead ECG to assess for these complications.

Corresponding evaluation results

1. The history is as important as the physical examination.
2. If a patient undergoes psychiatric treatment with drugs and does not follow the schedule of admission – this one fact alone puts him at a high risk of severe delirium.
3. If the patient was found naked, this increases the suspicion of stimulant use or abuse and increases the risk of severe delirium. Neuroleptic malignant syndrome, serotonin syndrome, and severe delirium may present with similar signs and symptoms.
4. If polypharmacy is suspected, hypertension and tachycardia are expected symptoms due to dopamine release. The use of benzodiazepines, antipsychotic drugs, as well as ketamine will reduce the effect of stimulation and improve the patient’s vital signs and behavior.
5. Be prepared for potential circulatory arrest as well as respiratory arrest.
6. If vasopressors are needed, it is recommended to administer epinephrine or norepinephrine rather than dopamine.

Key elements of documentation

1. The reason for the use of psychological and physical procedures and the use of a device for neurological/cardiovascular examination.
2. The reason for choosing this or that drug.
3. Data on the QT interval when using antiemetic drugs, haloperidol or droperidol and transfer of data to the receiving department.

Criteria for the effectiveness of aid provision

1. Recognition and treatment of hyperthermia.
2. Identifying the need for monitoring indicators of the cardiovascular and respiratory systems in case of poisoning by stimulants.
3. Assessment of presence and treatment of acute coronary syndrome with chest pain and shortness of breath.
4. Quick recognition and treatment of breathing disorders.
5. Quick recognition and treatment of disorders of the cardiovascular system.
6. Absence of injury to the patient and EMD specialists.
7. Access and monitoring were not lost during transport.