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- 1. International Trauma Life Support for Emergency Care Providers CHAPTER eighth edition International Trauma Life Support for Emergency Care Providers, Eighth Edition John Campbell • Alabama Chapter, American College of Emergency Physicians The Impaired Patient 20
- 2. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved The Impaired Patient Courtesy of Louis B. Mallory, MBA, REMT-P
- 3. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Objectives • List the signs and symptoms of patients under influence of alcohol and/or drugs • Describe some strategies you would use to help ensure cooperation during assessment and management of a patient under the influence of alcohol and/or drugs • Define excited delirium
- 4. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Objectives • List the special considerations for assessment and management of patients in whom substance abuse is suspected
- 5. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved The Impaired Patient • 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
- 6. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved The Impaired Patient • 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
- 7. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Substance Abuse • Guides as to whether your patient is under the influence of alcohol or drugs – A high index of suspicion combined with the results of the physical exam – The history obtained from the patient – Evidence at the scene
- 8. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Substance Abuse • Prescription medications contain the drug in the amount listed on the label • Street drugs are “cut” or mixed with other active drugs or inactive fillers. • Drugs used to cut the main substance can change effect of the drug and/or alter signs and symptoms • Drugs can therefore be stronger or weaker than usual
- 9. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Commonly Encountered Drugs • Methamphetamines commonly mixed with bath salts • Heroin can be cut with fentanyl – If more pure than usual, can lead to increased deaths • “Krokodil” = desomorphine – Similar effects to heroin but shorter acting – Associated with tissue damage and can lead to skin ulcers and gangrene, resulting in amputations of the limb
- 10. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Commonly Encountered Drugs • “N-bomb”—a group of designer drugs which target serotonin receptors and cause hallucinations – Also cause seizures, cardiac and respiratory arrest and death • Salvia—hallucinogen – Causes altered perceptions of external reality (unable to interact properly in his/her surroundings) – Experience dizziness, trouble walking and slurred speech
- 11. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Assessment • ITLS Primary and Secondary Surveys • Note: – Mental status – Respiration – Speech – Pupils – Needle marks © Pearson
- 12. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Mental Status Assessment • Altered mental status – Euphoria – Psychosis – Paranoia – Confusion – Disorientation – Due to head injury, shock, hypoglycemia until proven otherwise • All patients have an emergency medical condition until proven otherwise Courtesy of Louis B. Mallory, MBA, REMT-P
- 13. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Impaired Patient Assessment • Respirations – Significantly depressed Opiates and sedatives • Speech – Slurred Alcohol or sedatives – Ramble – Hallucinogens • Tachycardia/hypertension • Pain response Courtesy of Louis B. Mallory, MBA, REMT-P
- 14. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Pupils • Constricted – Opiates – Early barbiturate use • Dilated – Amphetamines – Cocaine – Hallucinogens – Marijuana • Fixed and dilated – High-dose barbiturates Courtesy of Louis B. Mallory, MBA, REMT-P
- 15. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved History • Obtain history from patient or bystanders to establish if substance abuse is involved – What was used? – When was it taken? – How much was taken? • Check with local poison control • Patents may deny use or abuse – Look for alcohol containers, pill bottles, injection equipment, smoking/snorting paraphernalia or unusual odors
- 16. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved The Impaired Patient • 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
- 17. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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 Do not argue—increases tension
- 18. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Interaction Strategies • Improving cooperation – Identify yourself and orient patient to surroundings – Ask what they prefer to be called – Treat with respect and avoid being judgmental – Acknowledge concerns and feelings – Let patients know what will be required of them – Ask close-ended questions for history
- 19. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved 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
- 20. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Excited Delirium • This syndrome is characterised by agitation and aggressive behavior: – From stimulants such as cocaine and methamphetamines – Often results in death of patients especially when they are restrained
- 21. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Excited Delirium • Patient exhibits: – Tachycardia – Hyperthermia – Diaphoresis – Hyperactivity – Hallucinations – Incredible strength • Patients who are restrained have died from “positional asphyxia” or cardiac dysrhythmias
- 22. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Excited Delirium Management • Decontaminate patient if they have been pepper sprayed – Tasers and pepper spray commonly used to subdue these patients • Prevent injury to self • Place on cardiac monitor • Rapidly sedate patient (ketamine, benzodiazepines or haloperidol) • Call in police • Consider secluding if danger to self
- 23. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Patients Who Refuse Care • What is the patient’s capacity to refuse treatment/care? • Must have no alteration of mental status (i.e. no head injury), not clinically intoxicated, no hypoxia or hypoglycemia • Must be able to understand risks and possible detrimental outcomes if they refuse care • DOCUMENT this capacity or lack thereof • If restrained, patients must always have a provider to manage the airway, should they vomit
- 24. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Restraints • Know local protocols – Law enforcement – Threat to self – Types of restraints Spinal immobilization Reeves sleeve Soft restraints Chemical © Pearson
- 25. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved NIDA 2009 USA Study • Teenage drug use decreasing • Belief that MDMA (ecstasy) not harmful • Concerned with nonmedical use of: – Hydrocodone (Vicodin) – Oxycodone (OxyContin)
- 26. Copyright © 2016 by Pearson Education, Inc. All Rights Reserved Summary • Know signs and symptoms of substance 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
Editor's Notes
- 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 may be impaired from substance abuse. 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.
- 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.
- It is extremely difficult to differentiate between patients under the influence and those experiencing a medical and/or trauma emergency.
- Therefore, the patient’s report of how much was used is helpful, but not 100% reliable indication of what symptoms to expect.
- “N-bomb” includes a group of designer drugs called 25B- NBOMe, 25C- NBOMe, 25I- NBOMe. These drugs target serotonin receptors.
- 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. An altered mental status can be seen in every form of substance abuse.
- 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.
- Speech can be slurred when using alcohol or sedatives. Hallucinogen use—patient may ramble when talking. Many drugs lessen the patients’ perception and response to pain, making your assessment more challenging.
- Patients who use barbiturates will have pupils that are constricted early on. High dose barbiturates—pupils will eventually become fixed and dilated.
- 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.
- 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. Avoid yelling at the patient. Respect the patient’s personal space. Avoid talking in a condescending manner. Acknowledge the patient’s concerns. Maintain eye contact.
- 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.
- Watch for clues regarding physical violence, such as verbal threats, aggressive posture by the patient, rapidly shifting eye movements, and fist clenching. If the situation becomes physical, you should back out to safety and allow law enforcement officers to perform their job.
- Patients are often difficult to handle because they can display incredible strength. Deaths attributed to the patient being placed in a prone position will hands behind the back and legs forward (“hog position”).
- It is believed that the effects of stimulants (e.g., cocaine, methamphetamine) lead to cardiac dysrhythmias and their signs reflect sympathetic nervous system stimulation. Cardiac monitoring leads may be difficult to apply due to diaphoresis. Intoxicated patients, especially those on stimulants, are at risk of death during transport.
- Know your jurisdiction’s policy on refusal of care. For emergency care providers to treat, patients must consent to care. Unresponsive patients are often able to be treated under implied consent.
- Restraint training is essential. 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.
- 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 Methylenedioxymethamphetamine MDMA (ecstasy) is harmful is declining 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).
- 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.