The Accidental or Intentional Use of a Drug - Essay Example

Emergency Treatment of patients with heroin overdose An overdose is the accidental or intentional use of a drug or medicine in an amount that is higher than normally used or prescribed (Ramsden and Friendship, 2007). Heroin is a powerful opiate that depresses the central nervous system trough the suppression of adrenaline. It can be sniffed smoked or injected and its use and abuse carries with it a high risk of overdose. This happens given the street strength of the drug that is usually 20 per cent but can in turn range from 10 per cent to over 60 per cent. The world of late has witnessed a heroin epidemic which has in turn resulted in a cataclysmic rise of the incidences of fatal and non-fatal heroin overdose in many countries. Deaths from opioid overdose increased 55-fold in Australia between 1964 and 1997 (Sporer, 2003). More recent statistics suggest that heroin abuse in Australia could be as high as 5-10 tonnes of heroin, which is equivalent to 50-100 tones of opium. However, the National Drug and Alcohol Research Centre (NDARC), UNSW, estimated in a study in 2000, that actual heroin consumption was approximately 2.3 tones per annum (NSW Office of Drug Policy, 2002). There are in fact those that suggest that heroin overdose is the single largest cause of death in heroin addicts. A patient overdosed on heroin may suffer from respiratory depression and may present symptoms like hypotension and hypothermia (Mostafa, 2004). The basic risk factor is that life threatening CNS and respiratory depression frequently occur just above the analgesic dose. Agonist activity at mu-receptors (OP3 receptors) is responsible for euphoria, analgesia, Risk factors include concomitant benzodiazepine use and the use of heroin in an atypical setting. The first step in the treatment is the primary survey wherein the patients’ basic symptoms like the vital signs and the breathing are recorded. It is also imperative to if first and foremost note whether the patient is conscious and breathing (Rodden, 1999). Airway protective reflexes and apnoea cause death in most cases of opioid intoxication (Ramsden and Friendship, 2007). The classic opioid symptoms consist of central nervous system depression, respiratory depression and miosis. Attention should therefore be given to airway, breathing and circulation. These can be managed along conventional manner. The second consideration to note is the patient’s age. Figure out the drugs that the patient has taken and the quantity in which these drugs have been administered. This could be ascertained by asking the patient himself if he is conscious or the one bringing him in-including the emergency personnel. This information is vital as this it forms the basis of further diagnosis and treatment. The second thing that needs to be ascertained is the duration of time that has passed since the drug was taken. The duration of the effects is dependent on the pharmacokinetics of the individual agent. Heroin intoxication is short (usually less than 6 hours). As far as the triage is concerned the cases of heroin overdose need to be given priority given the fact that the time between the intake of the drug and the time until the medication is administered is crucial and could form the difference between life and death. Since most heroin overdoses can be brought under immediate control within the first two hours or so this information is crucial as this will also determine the strength of the medication administered (Garrick et. al, 2000). The next most important point of concern is that needs to be ascertained whether heroin was taken with some other substance or in isolation given the fact that if taken with other anti-depressants it can be fatal. Alcohol abuse with the drug is also a consideration as it would have a more marked impact if consumed with alcohol. 12-lead ECG, BSL tests need to be run to check for deliberate poisoning. The secondary survey begins after the primary survey has been concluded and includes the activities like a record making of the patient’s complete medical history, a complete physical check is carried out, the lab tests are run, x-rays if needed are given and other special tests are also carried out. Beside this, in SS, the ED team carries out injury assessment and plans the destination that the patient’s treatment needs to take. The symptoms of the patient need to be recorded and the intensity of these symptoms needs to be placed under scanner as well. For example the respiratory problems and their intensity that the patient is experiencing would determine how much the overdose has impacted his system. Symptoms to be observed in the Emergency Department: There are a number of specific signs that can be placed under consideration when one considers a patient that is suspected to have suffered from an overdose (Maher and Ti Ho 2009). Given the time that it requires for the overdose to demonstrate impact ranges from 60-90 minutes, it would essential to get the indicative signs recognised as soon as possible. This is doubly underlined by the fact that an overdose if not treated correctly and quickly can turn out to be fatal. Heroine as an illegal opiate affects the central nervous system as a depressant. Its immense danger arises from the fact that it is deadly when mixed with other substances that have this effect like alcohol or with other opiates. Although it is difficult to predict the exact amount intake that constitutes an overdose, lethal doses can range from 200 mg to over 1,000 mg. for long-term users. Once the symptoms have been identified, the level of the dos needs to be quantified in order for further treatment to take place. It is for this purpose that urine and blood samples need to be taken and sent to the lab for a proper testing procedure. This will also help clarify the drugs alcohol consumed along with the heroin. The next most important step is where the skill on the part of the nursing staff comes into play. The idea is in essence to remove from the body any part of the drug or other abuse substances that have not already been absorbed into the body mechanism (Reis et. al., 2009) and . As has been noted earlier, vomiting is noticeably absent in cases of heroin overdose hence vomiting would need to be induced in order to clean the system. This can be done with the help of drugs like ipecac syrup or other vomiting inducing drugs. The next procedure to be followed is Gastric lavage, also called stomach pumping. This can be attempted to ensure that the insides of the stomach ate clean and free of any residual remnants of the drug, alcohol or heroin intake. In the procedure, a saline or salt water solution is used to rinse out the inside cavaties of the stomach also called a stomach pump. The idea is to insert a large flexible tube through the nose or mouth of the patient, down the throat, and into the stomach. Whatever is found in the stomach is then suctioned out with the help of the tube. A solution of saline (salt water) or regular tap water is pushed down into the tube to rinse out the stomach. The saline solution or water is then suctioned out. This process is repeated several times until the suctioned fluid is clear. Opioid intoxication is associated with the onset of CNS depression, and possibly of seizures. The best medication in dealing with these are tramadol and dextroproxypene. Activated charcoal is not routinely indicated. It may reduce length of stay if administered to patient presenting early after overdose with controlled release tablets (Ramsden and Friendship, 2007). Another method of ensuring that the toxins are flushed out is to give the patient a lot of Intravenous (IV) fluids. An intravenous line, a needle inserted into a vein, may be put into the arm or back of the hand. Fluids, either sterile saline (salt water solution) or dextrose (sugar water solution), can be administered through this line. Increasing fluids can help to flush the drug out of the system and to reestablish balance of fluids and minerals in the body. The pH of the body may need to be corrected by administering electrolytes such as sodium, potassium, and bicarbonate through the IV line. If drugs need to be administered quickly, they can also be injected directly into the IV line (Phillips and Johnson, 2000). There is another option available- that of activated charcoal which helps in the absorption of the drug through a tube or by ensuring that the patient swallows it. Laxatives and other medication is also given so that the patient urinates or defecates ensuring thereby that the drugs and toxins still residue in the system are flushed out as fast as possible. The idea in this entire process of treatment in the early part of emergency care is to ensure that the system is cleansed of the drugs and to prevent the further absorption of chemicals from the system. There are other ways of ensuring that the system is purified. These are a lot more radical and should be implemented only in cases that are extreme. The procedure to be implemented here is Hemodialysis, a procedure in which blood is circulated out of the body, pumped through a dialysis machine, then reintroduced back into the body. This process can be used to filter some drugs out of the blood and can clean the blood. It may also be used temporarily or long term if the kidneys are damaged due to the overdose. Antidotes that are available for some drug overdoses may be administered (Fry, Fox and Rubold, 1999). An antidote is another drug that counteracts or blocks the overdose drug. Psychiatric evaluation is performed if the drug overdose was taken deliberately. If the overdose is determined to be a deliberate act, further psychiatric care is provided while the patient is hospitalized (Tait, Ngo and Hulse, 2009). It is also difficult to predict the purity of heroin as it is at times mixed with substances such as Fentanyl. Factors in such cases that need to be placed under consideration while deterring whether or not there has in fact been an overdose is to consider user’s tolerance and the amount taken and the purity are all factors that determine whether someone will have a bad reaction to heroin. It might be the case that due to constant abuse spanning years in some cases the individual has built high levels of tolerance. There is thus a requirement on the part of the user to use more and more to for the experience or the high that they need. This varies from euphoria to an effort to stave off withdrawal. The first symptom that a medical practitioner has to be aware of is a slowing of the patient heart beat and breathing which could be fatal. The other signs that one would need to keep in mind in the phase where the diagnosis is being made are things like dry mouth, pinpoint pupils, muscle spasms, stopped breathing, cold and clammy skin, blue lips and fingernails, stomach spasms, weak pulse, constipation, low blood pressure, drowsiness, disorientation, extreme drowsiness, confusion, delirium, hallucination, seizures or coma. The first step that the practitioner therefore needs to ensure is a check for the vital signs are whether or not these are normal. This would mean a thorough check of the vital signs including blood pressure, breathing rate, pulse and temperature. After a check up of the vital signs the process of actual treatment has to start. The first step to be taken is an assessment of the sufficiency of ventilation that the patient is placed on given the fact that the primary danger of heroin is to slow breathing (Hall, 1996). If there is a problem the process naloxone should be administered as an anti-depressant. If however the patient is doing ok there without support then there is no need for administration of the anti depressant but the patient needs to be kept under constant observation nonetheless. Chances are that there would be problems, as most patients in cases of an overdose have insufficient respiration. They should thus be given a bag-valve-mask ventilation which can be followed by parenteral naloxone therapy. Endotracheal intubation should be avoided unless the patient does not respond to naloxone within 5 to 10 minutes of administration or there is some other compelling reason for invasive airway management. One needs to now analyze the details of the standard drug that needs to be administered in cases of heroin overdoses. The standard medication as has been mentioned earlier is Naloxone (brand name Narcan) (Ramsden and Friendship, 2007). It is in essence a short acting narcotic antagonist that is usually administered by intravenous injections. The drug is in fact used solely for the reversal of the impacts of heroin overdose in the emergency department. It plays a vital role in the prevention of heroin overdose relate deaths through the use that it has in ambulances and hospital emergency rooms. There are those that are also experimenting with its use by police officers and other public servants for use in emergencies while the paramedics get to the spot. The debate is still ongoing and as of now it can just be used by ED professionals. The proper naloxone route of administration is presently under some debate as well. In cases of a patient that is hypo-ventilating and is under suspicion for a heroin overdose, ideally an initial parenteral dose of 0.4 mg of naloxone, followed by a higher dose (1 to 2 mg) if no response occurs in 3 to 5 minutes, is generally recommended (Tait, Ngo and Hulse, 2009). Lower starting doses can be used for obvious heroin overdoses as long as ventilatory support is adequate. Higher naloxone doses may be necessary to reverse the effects of semi-synthetic oral opiates. Adequate doses could be repeated at intervals of 2-3 minutes up to a maximum of 10 kg (Lenton and Hargreaves, 2000). In most cases intravenous administration is the route that is taken for the administration of naloxone. There are those however that believe tin the intramuscular and subcutaneous routes and their related effectiveness. A recent pre-hospital study reported that intravenous (0.4 mg) and subcutaneous (0.8 mg) naloxone administration yielded similar results (Hall, Dregenhardt and Linskey, 1999). After the first few crucial hours pass, the patient needs to be protected with adequate ventilation should be observed in the emergency department for the next few hours at a minimum of about three hours. The medication that is provided usually looses its impact within an hour or so. There are always chances that the patient would illustrate symptoms of the intoxication and overdose all over again once the impact of the medicine starts to wear off. In these cases, further doses of naloxone need to be injected. Moreover, chances are that a number of patients would not respond to the medication administered and would continue to exhibit problems in breathing and respiratory compromises. In these cases patients demonstrating higher percentages of clinically significant cough or poor oxygenation need to be evaluated with chest radiography. The discharge planning and patient education work that is taken up by the nursing staff is mostly with respect to detoxification. This would be recommended as pretreatment procedure before residential therapeutic community treatment. The idea is to ensure that the patient and his family understand that in the absence of a proper route of detoxification and rehabilitation there would be instances of overdose again and the next time the patient might not be as lucky (Nolan, 2000). The patient can thus be recommended for further out patient drug treatment and opioid antagonist maintenance treatment. Efforts must also be made to ensure that the patient seeks psychiatric help in cases where the there was a clear attempt at suicide through heroin administration. Even in cases of addiction psychiatric help can be of use at times. In conclusion, therefore it maybe reiterated that the treatment and the medical management of a patient suffering from heroin overdose can usually follow a pattern of directions that would ensure that the death rate related to an overdose witnesses a significant fall over the next few years. The problem with the management of a heroin overdose induced emergency at most times is the fact that the patient is brought to the ED too late when the chances for the medical personnel to save him have diminished significantly. The need therefore is for a set of rules that ensure a faster system of aid and treatment for victims of heroin overdose, maybe even the system of domestic medication. Reference: Fry C, Fox S, Rumbold G, 1999, Establishing safe injecting rooms in Australia: Attitudes of injecting drug users, pub, Australian and New Zealand Journal of Public Health, Vol. 23 No.5, pp501-504 Garrick T M, Sheedy D, Abernethy J, Hodda A. E, Harper C. G, 2000, Heroin-related deaths in Sydney, Australia. 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