by Alan Batt. Last modified: 28/02/14
This is the first in our case study series. We’re looking for paramedics, student paramedics, EMTs and others worldwide to submit case studies in a similar format. These will provide for foundation reading on conditions and presentations, will contain links to articles of interest and may be of use to anyone doing university assignments or further research on a particular area. Submissions can be credited or anonymous based on your wishes. Submit your own case study here!
Patient & Apparent Chief Complaint
A 20 year old male, presents to ambulance crew through emergency call with altered level of consciousness, respiratory depression, extensive burns to left torso and flank secondary to IV heroin overdose. Patient is in recovery position upon arrival of crew.
Found in a collapsed state by friend (also IV heroin user), lying naked in a bedroom against the radiator. The friend was unable to rouse patient. Family doctor called for. Ambulance called for by doctor upon arrival at house. First aid administered by GP prior to ambulance arrival.
Initial Clinical Findings
- Airway – partially obstructed
- c-Spine – not indicated (MOI: excessive heat)
- Breathing – bradypnoea
- Circulation – Pulse present, irregular, skin colour pale, cap refill delayed (>2 sec)
- Disability – Patient responding to pain only
- Respiratory Depression secondary to heroin overdose
- Mixed thickness (partial and full thickness) burns to extensor surface of left arm from shoulder to elbow; left lateral thoracic wall; left lateral abdominal wall; lateral aspect of left flank and left buttock.
- A: Unknown allergies
- M: Unknown medications
- P: Unknown past medical history
- L: Last oral intake unknown
- E: Found collapsed in bedroom
Observations – Pre-hospital
- Pulse rate 142bpm
- Pulse rhythm Irregular
- ECG rate 142bpm
- ECG rhythm Sinus Tachycardia
- Resp rate 8
- Resp quality Shallow in both lungs
- SpO2% 99% on O2 via BVM at 15lpm
- Cap Refill >2secs
- BP 90/P
- Pupils PEARRL, size 1
- GCS 11/15 (E2, V4, M5)
- BGL 8.4mmol/l
OPA inserted and tolerated. O2 @15lpm commenced. Naloxone 800mcg IM. Sterile dressings placed over burns. Transported to ED.
Patient triaged as Category 1 (Life-Threatening Condition) with Burns, Overdose & Poisoning. Brought directly to Resus room. Aggressive airway management, fluid resuscitation commenced. 12 lead ECG acquired. CXR and bloods acquired. Wounds reviewed by Plastic Surgery, for debriding in theatre the following day. Patient transferred to Observation Room for overnight observations. Patient received Naloxone infusion over 23 hours.
Identification of interventions initiated and rationale
- Oropharyngeal airway – to protect the airway due to decreased level of consciousness
- Pulse oximetry – to monitor oxygen saturation levels in the blood
- Supplemental oxygen – to re-oxygenate patient after period of bradypnoea
- 3 Lead ECG – to identify any life-threatening arrhythmias
- Naloxone IM – to reverse the respiratory depression caused by narcotic overdose
- Cooling of burns – to stop the burning process
- Sterile dressings over burns – TBSA > 10% so water based dressings contraindicated
- Fluid resuscitation – to re-hydrate the patient due to plasma loss caused by burns
- 12 Lead ECG – to identify any life-threatening arrhythmias or ECG changes indicative of myocardial damage (secondary to hypoxia etc.)
- CXR – to identify pneumonia, pneumothorax, pleural effusion etc. that may increase morbidity
- Blood tests – to identify any electrolyte imbalances caused by fluid loss etc.
- Urinary catheter – to monitor urinary output due to fluid resuscitation being commenced, and to ensure adequate renal function
- Naloxone infusion – to continue to reverse the respiratory depression caused by narcotic overdose, and to reduce opiate level in the body
- Class: Class A, controlled under Misuse of Drugs Act, 1977
- Presentation: Brown (adulterated form) or white (pure form) powder
- Administration: IV, sniffed/inhaled, swallowed; IV use penetrates blood-brain barrier easily
- Effects: Analgesia, euphoric rush, drowsiness, sexual excitement, feeling of calm and peacefulness
- Side-effects: Constipation, palpitations, arrhythmias, rash, nausea vomiting, sweats, bone and muscle pain, diarrhoea, cramps, altered LOC, coma, death
- Nicknames: Smack, junk, horse, china white, chiva, H, tar, black, fix, speed-balling, dope, brown, dog food, gear, negra, nod, white horse, and stuff.
(Drugs & Alcohol Programme, 2008)
Naloxone (Opioid Antagonist)
- Presentation: Ampoule (0.4mg/1ml)
- Administration: IV, IM, IN or SC.
- Effects: Reverses respiratory depression caused by overdose; reverses analgesic effects of narcotics
- Side-effects: Nausea, vomiting, agitation, seizures, aggression
- Additional Info: Administration may precipitate acute withdrawal syndrome
Heroin users and heroin related deaths in Ireland
There are an estimated 14,452 heroin users in Ireland (Kelly et al, 2003). In the majority of the EU, drug related deaths have decreased, yet Ireland is still experiencing increases (EMCDDA, 2002). It is estimated that injecting heroin users have a 20 to 30 time increased risk of dying when compared to non-users of the same age. (EMCDDA, 1997). Heroin use, whilst at one time restricted to inner city Dublin, is now widespread throughout Ireland, most commonly smoked.
Morbidity of non-fatal heroin overdoses
As per Warner-Smith et al. (2002) there is extensive morbidity both direct and indirect, associated with non-fatal heroin overdoses. In relation to this case study, 24% of heroin users interviewed had received burns due to an overdose, similar to the patient discussed above. Injuries sustained due to falls (40%), and assault while unconscious (14%) were other indirect morbidity factors reported.
Direct factors including peripheral neuropathy (49%) and limb paralysis (26%) were reported by users due to extended periods of lying on limbs during unconsciousness due to overdose. Other side effects reported included vomiting, chest infections, seizures, pulmonary oedema and palsy.
Overdose training for drug users
In a study carried out in Dublin, Ireland drug users agreed that overdose training should be provided to users (Bolger, 2007). The study interviewed 10 heroin users who had personally experienced an overdose within the last 12 months, and all had witnessed another person overdosing. All 10 showed a lack of treatment knowledge for overdose. The study concludes by recommending training for drug users on overdose treatment, supervised drug injecting facilities and pilot Naloxone distribution programmes for drug users. This view is re-iterated by Dettmer et al (2001), who study two successful Naloxone distribution schemes, one in Berlin and one in Jersey. Programs that distribute naloxone to opiate users and their acquaintances have been successfully implemented in a number of cities around the world and have shown that non-medical personnel are able to administer naloxone to reverse opiate overdoses and save lives (Bazazi et al., 2010)
- Bolger, A. (2007) Drug users’ experiences and perspectives of overdose: an exploratory study. MSc thesis submitted to Dublin City University.
- Drugs and Alcohol Programme (2008) [http://www.drugs.ie/drugtypes/drug/heroin] Accessed 28/01/2014.
- EMCDDA (1997) 1997 Annual Report of the State of the Drugs Problem in the European Union. Lisbon: EMCDDA
- EMCDDA (2002) 2002 Annual Report of the State of the Drugs Problem in the European Union and Norway. Lisbon: EMCDDA
- Kelly, A et al (2003) A 3 Source Capture/Recapture Study of the Prevalence of Opiate Use in Ireland 2000 to 2001. Dublin: National Advisory Committee on Drugs
Tags: case study, drug, heroin, OD, overdose
The antidote for acetaminophen is acetylcysteine. Acetylcysteine is administered intravenously and is usually more effective if given within 8 - 10 hours from the time of ingestion. Mucomyst is the oral preparation of acetylcysteine that is administered orally. Incidentally, Mucomyst can be used as a mucolytic expectorant to help with the clearance of thick mucus secretions.
Atropine is used as the antidote for anticholinesterase or organophosphate poisoning. It is usually administered intravenously with an initial dose of 1-2 mg in adults with subsequent doubling of the dose every 15 minutes if there is no response. Atropine can also be used for rapid onset mushroom poisoning especially when there is a predominance of muscarinic excess symptoms such as bradycardia, hypotension, rhinorrhea, bronchospasm, respiratory distress, hypersalivation, abdominal cramping, and diarrhea.
In the case of tricyclic antidepressants and other membrane depressant cardiotoxic drugs, bicarbonate sodium is the antidote of choice. The dose is usually 1-2 mEq/kg administered intravenously. Cautious use is advised for patients with heart failure. In addition, clinicians should closely monitor these patients for signs of sodium overload.
The antidote for calcium channel blockers is calcium administered in large doses. The initial dose is usually 15 mg/kg intravenously.
The antidote for digoxin is digoxin specific antibodies. Each vial of digoxin antibodies binds approximately 0.5 mg of digoxin. Digoxin antibodies are usually indicated in patients with arrhythmias and hyperkalemia.
Deferoxamine is used in cases of intoxication with iron salts. 100 mg of deferoxamine administered intravenously binds 8.5 mg of iron.
An overdose of caffeine and theophylline is usually treated with Esmolol. Esmolol is a short acting beta blocker, and the dose for administration is 25 - 50 mcg/kg/min intravenously.
Methanol and ethylene glycol intoxication are usually treated with ethanol administration. Fomepizole is also an antidote to methanol and ethylene glycol intoxication and is much more convenient to use than ethanol. The dose for Fomepizole is 15 mg/kg and can be repeated every 12 hours.
Benzodiazepine overdose can be reversed with Flumazenil. In adults, the dose is 0.2 mg intravenously which can be repeated up to a maximum of 3 mg. Flumazenil should not be administered in patients with seizures, benzodiazepine dependence, or in cases of tricyclic overdose.
Cyanide poisoning is treated with hydroxocobalamin which converts cyanide to cyanocobalamin which is Vitamin B12. The dose of hydroxocobalamin is 5 g over 15 minutes intravenously.
Beta blocker overdose is managed by administering glucagon which reverses the beta blocker effects. 5 - 10 mg iv of glucagon is initial dose used to reverse the bradycardia and hypotension associated with beta blocker overdose.
Naloxone (Narcan) is used as the antagonists of opioid and other narcotics. Usually, 0.4 mg of naloxone is given initially and can be repeated up to a maximum of 2 mg. Naloxone can be administered intramuscularly, subcutaneously or intravenously. Larger doses may be necessary to reverse the effects of overdose from codeine, propoxyphene or fentanyl derivatives. It is also important to note that the duration of action for naloxone is usually 2 -3 hours while that of the intoxicant narcotic may be significantly longer.
Carbon monoxide poisoning can be either accidental or intentional. It is usually treated with 100% oxygen administered via a non-rebreather mask. Hyperbaric chambers can be used in cases of severe poisoning.
Physostigmine is used to treat the delirium associated with the anticholinergic drugs. Physostigmine can cause bradycardia and can increase bronchial secretions and even cause seizures. Do not use physostigmine in the case of tricyclic antidepressant overdose. In the case of physostigmine overdose, atropine can be used as an antidote.
Pralidoxime is also used to treat organophosphate and cholinesterase inhibitor overdose; although, the benefits in organophosphate overdose are not well established.