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Street Drugs Part 4: Prescription for Trouble

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Title: Street Drugs Part 4: Prescription for Trouble


1
Street Drugs Part 4Prescription for Trouble
  • Robert S. Cole
  • Paramedic, CCEMT-P

2
Overview
  • We will review some common principles of caring
    for the Pharmacologically gifted
  • We will focus on some of the particular problems
    with prescription and OTC drugs
  • We will discuss 4 CLASSES of the drugs that every
    paramedic should know.
  • There is no way we can be all inclusive in an
    hour so bear with me.

3
Drugs we will cover
  • Triclyclic Anti-depressants
  • SRI anti-depressants
  • Benzodiazepines
  • MOAIs
  • OTC Drugs

4
TRICYCLIC ANTIDEPRESSANT
  • Leading cause of death in intentional overdoses
  • Began to be used in the 50s
  • Approx 1 million cases of TCA overdose per year -
    400 fatalities.

5
BACKGROUND
  • Tricyclic drugs enhance the concentrations of
    norepinephrine and serotonin.
  • These neurotransmitters, known as monoamines,
    once been secreted, must then be inactivated by a
    variety of mechanisms including reuptake into the
    secreting cells.
  • Tricyclics impede this reuptake process so that
    the monoamines remain active longer after
    secretion,
  • Some Tricyclic side effects have similar effects
    on other neurotransmitters in the CNS, notably
    histamine and acetylcholine.

6
NAMES OF TRICYCLIC ANTIDEPRESSANTS
  • Amitriptyline (Elavil)
  • Amoxapine (Asendin)
  • Clomipramine (Anafranil)
  • Desipramine (Norpramin)
  • Doxepin (SinequanAdapin)
  • Imipramine (Tofranil)
  • Nortryptyline (Aventyl Pamelor)
  • Protriptyline (Triptil, Vivactil)
  • Trimipramine (Surmontil)

7
Level of Sedation
  • Sedative
  • Dothiepin Prothiaden
  • Amitriptyline
  • Clomipramine Anafranil
  • Maprotiline
  • Mianserin
  • Less-sedating
  • Desipramine
  • Imipramine
  • Lofepramine Gamanil
  • Nortriptyline
  • Stimulant
  • Protriptyline

8
SIGNS AND SYMPTOMS OF TRYCYCLIC OVERDOSE
  • Primarily concerned over Cardiac and Neurologic
    problems
  • Cardiovascular QRS widening, conduction
    abnormalities, Tachycardia, ectopy, dysrhythmias,
    hypotension
  • Neurologic Rapid mental status
    deterioration,confusion, hallucinations
    (uncommon), coma, seizures (lowers SZ
    threshold), dilated pupils
  • Other Renal failure, ARDS, s/s histamine and
    anticholinergic stimulation
  • Acidosis may complicate severe overdose
  • Onset Toxicity generally develops within 4-6
    hours (may be sooner for large amounts)

9
Basic Treatment
  • Detailed scene search, Hx taking
  • Good aggressive airway management
  • Aspiration precautions
  • Seizure precautions
  • V.O.M.I.T.
  • R/O other causes. (BG, Hx of events, etc.)
  • Beware of poly-pharm ODs
  • Consider either oral or NG/OG charcoal.

10
Focused Treatment
  • Hypotension Fluid challenges
  • Poly-Pharmacy OD?
  • Narcan 0.4-2 mg SIVP
  • Romazacon is contraindicated
  • Cardiac toxicity
  • Bicarb 50-100 meq IV, 100 meq/1000 cc NACL,
    titrate for decrease in s/s.
  • Lidocaine, Bretylium per ACLS,
  • Procainamide and Amioroderone are
    contraindicated. As are other drugs that widen
    the QRS.
  • Seizures Benzos
  • Transport to a tertiary care facility regardless
    of perceived stability is recommended.

11
Long Term effects
  • Renal Failure
  • Liver problems?
  • Prolonged QT interval
  • CHF
  • Hyponatremia

12
Interactions
  • Anticholinergic and sympathomimetic meds may be
    additive to the toxic effects of a TCA.
  • Histamine blockers may raise TCA levels
  • Thyroid supplements may increase severity of
    cardiovascular side effects
  • TCAs potentiates the sedative effect of alcohol
    and benzos on the CNS on the CNS.

13
Take Home Information
  • Beware of Poly-Phar ODs
  • Bicarb and benzos as needed
  • Avoid Amiodarone and Procainamide

14
Selective Serotonin Re-uptake Inhibitors (SSRIs)
15
SSRI anti-depressants
16
BACKGROUND
  • Replaced TCAs as the most common pre-scribed
    anti-depressant
  • Focuses on serotonin (5HT) re-uptake and has no
    effect on nor-epinephrine
  • Much safer profile than TCAs
  • Are still taken by the depressed during ODs
    because of availability
  • Prozac (an SSRI) has a relative risk 6.6 times
    higher for deliberate self-harm (DSH) than the
    tricyclic antidepressant Amitriptyline and 3.5
    time higher than the average of tricyclic
    antidepressants examined in one study.

17
NAMES
  • Citalopram (Cipramil)
  • Fluoxetine (Prozac)
  • Fluvoxamine (Faverin)
  • Paroxetine (Seroxat)
  • Sertraline (Lustral).

18
Morbidity
  • SSRI antidepressants are rarely fatal in
    overdose when taken alone. During the 10 years
    that SSRI antidepressants have been marketed,
    there have been remarkably few fatal overdoses
    reported in the literature or to the AAPCC or FDA
    involving ingestion only of an SSRI.
  • SSRI overdoses in combination with alcohol or
    other drugs are associated with increased
    toxicity, and almost all fatalities involving
    SSRIs have involved co-ingestion of other
    substances.
  • SSRI safety in overdose by Barbey JT, Roose SP
    Division of Clinical Pharmacology, Georgetown
    University Medical Center, Washington, DC, USA.
    J Clin Psychiatry 1998 59 Suppl 1542-8

19
S/S OF AN OVERDOSE
  • Minor to moderate overdoses (up to 30 times the
    common daily dose) are associated with minor or
    no symptoms
  • Major overdoses (30-60 times daily dose)
  • Nausea vomiting
  • lethargy
  • sedation
  • At very high doses (gt 75 times the common daily
    dose), more serious adverse events, including
    seizures, electrocardiogram (ECG) changes, and
    decreased consciousness may occur.
  • No evidence that seizures occur following
    overdose of the SSRI agents.

20
Serotonin Syndrome
  • Patients concomitantly ingesting
    dextromethoraphan, monoamine oxidase inhibitors,
    MDMA/PMA Ecstasy and other serotonergic agents
    may develop a "serotonin syndrome."
  • Characterized by agitation, hyperthermia,
    sympathetic hyperactivity, severe hypertension,
    altered muscle tone and seizures.
  • Occurs within 2 hours of ingestion of offending
    agent and resolves 6 -24 hours after
    discontinuing the agent.

21
BASIC TREATMENT
  • Supportive
  • Standard ALS
  • Observe of cardiac toxicity in case of
    poly-pharmacy overdoses.
  • Transport

22
FOCUSED TREATMENT
  • Serotonin syndrome
  • Benzodiazepines, hydration and cooling are the
    mainstays of therapy.
  • Neuromuscular blockade (with EEG monitoring) may
    be necessary for refractory hyperthermia and
    increased muscle activity.

23
Long Term effects
  • SEROTONIN SYNDROME OUTCOME
  • mortality rate 11
  • ICU admission 40
  • intubated 25
  • cause of death
  • cardiovascular collapse
  • rhabdomyolysis
  • DIC
  • ARDS

24
Interactions
  • Opioids, Lithium, TCAs, MDMA all increase
    available CNS serotonin and may precipitate
    serotonin syndrome or simply increase sedation
    depending on levels

25
Detox, Dependence and Withdrawal
  • Abrupt discontinuation may cause serious
    withdrawal reactions that include crashing into
    depression with possible suicidal and/or violent
    behavior.
  • It is highly recommended to gradually taper off
    SSRI
  • Also includes dizziness, trouble with balance or
    coordination, headaches, nausea, fatigue or
    lethargy, tingling, electric shock-like
    sensations, insomnia, and vivid dreams. Less
    common reactions are gastrointestinal discomfort
    and flu-like symptoms.

26
Take Home Information
  • SSRIs are less cardio toxic than TCAs
  • Most side effects are easily manageable
  • Serotonin Syndrome , while rarely seen, can be
    life threatening
  • Serotonin withdrawal will be more commonly found.

27
BACKGROUND
  • Benzodiazepines (BZDs) are sedative-hypnotic
    agents that were first introduced in 1960.
  • Because of their widespread popularity, these
    drugs commonly are abused. In addition, BZDs
    frequently are used in overdose, either alone or
    in association with other substances
  • In addition they are used in illicit activities
    such as date rape.

28
Background
  • Most of BZDs effects come from its stimulation
    of the Gamma-aminobutyric acid (GABA) sites.
  • Benzodiazepines generally are thought to be safe
    and death is rare. It usually occurs in
    conjunction with concomitant alcohol ingestion or
    use of other sedative-hypnotics..
  • Intravenous administration is associated with
    greater degrees of hypotension than other routes
    of administration and occasional cardiac and
    respiratory arrest.

29
S/S OF AN OVERDOSE
  • Dizziness
  • Confusion
  • Drowsiness
  • Blurred vision
  • Unresponsiveness
  • Nystagmus
  • Hallucinations
  • Slurred speech
  • Ataxia
  • Coma
  • Weakness
  • Altered mental status, impairment of cognition
  • Amnesia
  • Paradoxical agitation
  • Respiratory depression
  • Hypotension

30
BASIC TREATMENT
  • Supportive
  • Airway management
  • EKG, IV, Etc
  • Activated charcoal -- Most useful if
    administered within 4 h of ingestion. Repeat
    doses may be used, especially with ingestion of
    sustained release agents. Limited outcome studies
    exist, especially when administration is more
    than 1 h of ingestion.

31
FOCUSED TREATMENT
  • Romazicon if BZD is the only confirmed agent that
    works similarly on the GAPA sites as Narcan does
    on the Opiate sites.
  • Dose
  • 0.2 mg IVP
  • Repeat 0.3 Mg
  • Max 0.5 mg to 1 mg.
  • Caution with mixed drug overdose toxic effects
    due to other drugs taken in overdose (eg, cyclic
    antidepressants) may occur with reversal of
    benzodiazepine effects (I.e. SZ suppression)
  • Beware of use in the chronic BZD pt (greater than
    4 weeks)

32
Interactions
  • Any drug that has sedative effects may expect to
    be potentiated by a BZD.
  • BZD may suppress the SZ activity in a TCA
    overdose, masking the TCA.

33
Detox, Dependence, and Withdrawal
  • Benzodiazepine withdrawal syndrome is believed to
    be caused by a dampening of the action of GABA as
    neuroadaptivity causes GABA to become dependent
    on stimulation from the benzodiazepine to
    initiate its primary action.
  • Most s/s are the reverse of the desired effect of
    a benzo.
  • Worst case scenario onset of seizures

34
TAKE HOME INFORMATION
  • Supportive care is best
  • Be familiar with BZD withdrawal syndrome
  • Indiscriminate use of Romazicon is bad.
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