Substance Abuse, Anaphylactic Reactions, Environmental Injuries, and Heat Related Illnesses

Alcohol and Drug-Related Emergencies

Recognizing Alcohol Withdrawal: Delirium Tremens (DTs)

• Delirium Tremens (DTs) are a severe form of alcohol withdrawal.
• Signs and symptoms of DTs include:
  • Confusion and restlessness.
  • Unusual or "insane" behavior.
  • Hallucinations.
  • Gross tremors of the hands.
  • Profuse sweating.
  • Hypertension (high blood pressure).
  • Tachycardia (rapid heart rate).

Managing Patients with Seizures or DTs

• Any patient experiencing seizures or DTs requires immediate transport to a medical facility.

Patient Assessment for Alcohol/Drug-Related Emergencies

• Standard Precautions: Always prioritize standard precautions.
• Airway and Respiratory Problems:
  • Be vigilant for airway and respiratory issues.
  • Be prepared to perform airway maintenance, including suctioning and proper patient positioning, especially if the patient loses consciousness, seizes, or vomits.
  • Position the patient to prevent aspiration of vomitus.
  • Keep a rigid-tip suction device readily available.
  • Administer oxygen and assist respirations as necessary.
• Trauma Assessment: Assess for any trauma the patient may be unaware of due to intoxication.
• Mental Status Monitoring: Observe for changes in mental status as alcohol is absorbed.
• Communication: Attempt to keep the patient alert by talking to them.
• Vital Signs: Continuously monitor vital signs.
• Shock Management: Treat for shock.
• Protection: Protect the patient from self-injury.
• Law Enforcement Assistance: Request assistance from law enforcement if needed.
• Seizure Monitoring: Stay alert for seizures.
• Transport: Transport the patient to a medical facility.

Substance Abuse

Definition

• Substance abuse is defined as the use of a chemical substance for non-therapeutic (non-medical) purposes.

Approach to Patient Care

• Recognize that individuals who abuse drugs or other chemical substances are ill and need professional emergency care like any other patient.

Commonly Abused Substances

• Uppers (Stimulants):
  • Affect the nervous system and excite the user.
  • Examples: caffeine, amphetamines, cocaine.
• Downers:
  • Have a depressant effect on the central nervous system.
  • Examples: barbiturates, Rohypnol ("Roofies"), GHB.
• Narcotics:
  • Produce stupor or sleep and are often used to relieve pain.
  • Examples: codeine, OxyContin, heroin.
  • Overdose signs: coma, pinpoint pupils, respiratory depression.
• Hallucinogens:
  • Mind-altering drugs that affect the nervous system to produce intense excitement or distorted perceptions.
  • Examples: LSD, PCP, certain mushrooms, ecstasy.
• Volatile Chemicals:
  • Produce vapors that are inhaled, resulting in an initial "rush" followed by depression.
  • Examples: cleaning fluid, glue, model cement.
• "Designer Drugs":
  • Chemicals that are structurally similar to traditional drugs but have slight differences in their molecular formula.
  • They produce similar (or greater) effects but may not be covered by existing drug laws due to their chemical variations.

Scene Assessment in Substance Abuse Cases

• It is crucial to recognize drug abuse, especially at the overdose level, and to associate specific signs and symptoms with particular drugs and drug withdrawal.
• Signs and symptoms can differ among patients, even with the same substance.

Specific Signs and Symptoms

• Uppers:
  • Excitement, increased pulse and breathing rates, rapid speech, dry mouth, dilated pupils, sweating, prolonged wakefulness.
• Downers:
  • Sluggishness, sleepiness, poor coordination, and slowed pulse and breathing rates.
• Narcotics:
  • Reduced pulse rate and depth of breathing, constricted pupils, relaxed muscles, profuse sweating, sleepiness, coma, respiratory arrest, or cardiac arrest.
• Hallucinogens:
  • Fast pulse rate, dilated pupils, flushed face, hallucinations, distorted perception of time and environment.
• Volatile Chemicals:
  • Dazed appearance, loss of contact with reality, swollen membranes in the nose and mouth, tingling sensations, changes in heart rhythm, coma.

Important Considerations

• Substance abusers might be using multiple drugs simultaneously.
• Gather information from signs and symptoms, the scene, bystanders, and the patient to determine substance abuse; use "medication" instead of "drug" initially.
• Never assume drug abuse is the only problem; be aware of underlying medical emergencies, injuries, or combinations of issues.

Withdrawal

• Withdrawal occurs when a long-term drug user abruptly stops taking the drug.
• Symptoms:
  • Shaking
  • Anxiety
  • Nausea
  • Confusion and irritability
  • Hallucinations (visual or auditory)
  • Profuse sweating
  • Increased pulse and breathing rates

Patient Assessment for Substance Abuse

• Standard Precautions: Take standard precautions.
• Scene Safety: Ensure the scene is safe.
• Primary Assessment: Perform a primary assessment.
• Basic Life Support: Provide basic life support if needed.
• Airway Management: Be alert for airway problems and inadequate respirations or respiratory arrest.
• Oxygenation: Provide oxygen and assist ventilations if needed.
• Naloxone Administration: If the patient has depressed mental status threatening the airway and respiratory failure, and local protocols allow, administer naloxone intranasally.
• Shock Treatment: Treat for shock.
• Communication:
  • Talk to the patient to gain confidence and maintain responsiveness.
  • Use their name, maintain eye contact, and speak directly to them.
• Physical Exam:
  • Perform a physical exam to assess for injuries to all body parts.
  • Assess carefully for signs of head injury.
  • Look for soft-tissue damage on extremities from drug injection ("tracks"), which appear as darkened or red areas of scar tissue or scabs over veins.
• Protection: Protect the patient from self-injury and attempts to hurt others.
• Law Enforcement Assistance: Request law enforcement assistance if needed.
• Transport: Transport the patient as soon as possible.
• Medical Direction: Contact medical direction per local protocols.
• Reassessment: Perform reassessment with monitoring of vital signs.
• Seizure and Vomiting Precautions: Stay alert for seizures and vomiting that could obstruct the airway.
• Reassurance: Continue to reassure the patient throughout all phases of care.

Anaphylactic Reactions

Basic Principles

• The body's immune system naturally reacts to foreign substances to eliminate them.
• An allergic reaction is an exaggerated immune response.
• An allergen is a substance that causes an allergic reaction.
• Anaphylaxis (anaphylactic shock) is a severe, life-threatening allergic reaction.
  • It involves a drop in blood pressure (hypotension).
  • Tissue swelling, including respiratory tissues, can lead to respiratory failure.

Causes of Allergic Reactions

• Insects (e.g., bees, wasps, hornets, yellow jackets).
• Foods (e.g., nuts, eggs, milk, shellfish).
• Plants (e.g., poison ivy, poison sumac, poison oak).
• Medications (e.g., penicillin).
• Latex (affecting both patients and healthcare professionals).
• Other substances (e.g., dust, chemicals, soaps, makeup).

Monitoring

• Severe reactions can be delayed, and mild reactions can quickly escalate to anaphylactic shock.
• Close monitoring of the patient is essential.

Signs and Symptoms of Allergic Reactions/Anaphylactic Shock

• Skin:
  • Itching
  • Hives
  • Flushing
  • Swelling of the face, neck, hands, feet, or tongue
  • Warm, tingling sensations in the face, mouth, chest, hands, and feet
• Respiratory:
  • Tightness in the throat or chest
  • Cough
  • Rapid breathing
  • Labored, noisy breathing
  • Hoarseness, muffled voice, or loss of voice
  • Stridor
  • Wheezing (audible without a stethoscope)
• Cardiac:
  • Increased heart rate
  • Decreased blood pressure
• Generalized Findings:
  • Itchy, watery eyes
  • Headache
  • Runny nose
  • Sense of impending doom
• Signs and Symptoms of Shock:
  • Altered mental status
  • Flushed, dry skin or pale, cool, clammy skin
  • Nausea or vomiting
  • Changes in vital signs: increased pulse, increased respirations, decreased blood pressure

Anaphylaxis Definition

• To be considered anaphylaxis, the patient must have either respiratory distress or signs and symptoms of shock.

Patient Assessment for Anaphylaxis

• Standard Precautions: Take standard precautions.
• Primary Assessment: Address immediately life-threatening problems (ABCs).
• Secondary Assessment: Gather information about:
  • History of allergies
  • Exposure details
  • Signs and symptoms
  • Progression of symptoms
  • Previous interventions
• Baseline Vital Signs: Assess baseline vital signs and obtain the rest of the past medical history.

Emergency Care for Anaphylaxis

• Airway and Breathing Management:
  • Administer high-concentration oxygen via a nonrebreather mask.
  • If the patient has an altered mental status, open and maintain the airway.
  • If the patient is not breathing adequately, provide artificial ventilations.
• Epinephrine Auto-Injector: Determine if assisting with or administering an epinephrine auto-injector is appropriate.
  • Considerations for Auto-Injector Use:
    • Has the patient had a prior allergic reaction to the same substance AND is currently experiencing respiratory distress or shock?
      • If yes, contact medical direction and follow orders regarding the use of a prescribed auto-injector or the administration of epinephrine.
      • Record the administration, transport, and reassess after 2 minutes.
    • Has the patient had a past allergic reaction to the same substance BUT is not currently wheezing or showing signs of respiratory distress or shock?
      • Continue assessment and consult medical direction.
      • Administer epinephrine per medical direction's orders if the patient has an auto-injector.
    • Patient is exhibiting respiratory distress or signs/symptoms of shock and has a history of allergic reactions to the same substance BUT does not have a prescribed epinephrine auto-injector available.
      • If protocols do not allow carrying and administering epinephrine auto-injectors, provide shock care and transport the patient immediately.
    • Patient has a prescribed epinephrine auto-injector (or protocol allows you to carry and use one).
      • If the patient meets the criteria but you can not administer consider requesting ALS

Environmental Injuries

Introduction

• Environmental injuries have immediate and potential long-term effects.
• Immediate effects:
  • Significant loss of performance.
  • Reduced efficiency.
  • Loss of duty time due to systemic heat injury.
• Long-term effects of heat stress (less apparent):
  • Progressive loss of performance capability.
  • Increased susceptibility to other forms of stress.
  • Reduced temperature tolerance.

Heat Illnesses and Injuries

• Military populations are prone to heat disorders due to increased heat stress during battle or training that limits normal compensatory behaviors.
• The spectrum of heat illnesses ranges from mild to severe as body temperature increases.
• Hyperthermia: Elevated body core temperature.
  • Occurs when the body's cooling system cannot regulate temperature.
  • Degrades mission performance and morale, increases the risk of accidents, and risks safety.
  • Sweating is the primary cooling mechanism.
  • Unrecognized and untreated heat stress can lead to serious health problems, such as heat stroke.
• Heat Rash:
  • Skin irritation from heat exposure, appearing as red bumps on the neck, groin, or under the arms.
  • Relief: Remove from heat, apply cooling water or non-greasy lotion.
• Heat Syncope (Fainting):
  • Most likely to occur when un-acclimated personnel are first exposed to heat stress.
  • Avoided by not requiring prolonged standing in heat, especially after exercise.
• Heat Cramps:
  • Painful cramps, usually affecting the extremities and abdomen.
  • Occur in individuals performing vigorous physical exercise in heat stress conditions.
  • Relieved by reducing exercise intensity or ceasing activity.
  • Electrolyte replacement can assist, but salt tablets are not recommended.
• Heat Exhaustion:
  • More serious heat injury related to dehydration or salt depletion.
  • Care: Call for medical aid, move to a shaded and ventilated area, and loosen or remove clothing (unless in a chemical environment).
  • Fan the individual and have them slowly drink at least one quart (or one full canteen) of water over 20 minutes (faster if thirsty).
  • Personnel need medical treatment to ensure proper recovery and rehydration.
• Heat Stroke:
  • Results when the body's ability to maintain core body temperature fails.
  • Medical Emergency.
  • Requires rapid cooling and medical attention for survival.
  • Immediately cool the victim as rapidly as possible, evacuate to a medical treatment facility while continuing cooling measures.
  • Any cooling method can be used (helicopter downdraft, fanning, ice water).

Heat Related Injuries Treatment

• Remove the patient from the hot environment.
• Assess patient's vital signs.
• Administer O_2
• Loosen and/or remove clothing
• Apply cool packs to the neck, groin, and axillary regions
• Cool by fanning
• Keep skin wet
• If the patient is responsive, give cool water
• Apply moist towels to cramps
• If the patient is unresponsive, place on left side
• Assess for muscular cramps
• Assess for weakness or exhaustion
• Assess for rapid shallow breathing
• Assess for weak pulse
• Assess moist pale skin, normal to cool
• Assess for heavy perspiration or little to none
• Assess for level of consciousness
• Assess for dilated or pinpoint pupils
• Place the patient in a supine position
• Treat for shock
• Transport

Heat Stress Monitoring

• Dry-Bulb (DB) Temperature:
  • The prevailing air temperature measured with an ordinary alcohol-in-glass thermometer.
  • The bulb is kept dry and shielded from radiation (radiant heat, such as sunlight).
• Wet Bulb (WB) Temperature:
  • Measured with a thermometer similar to that used for DB temperature.
  • A wet wick is fitted closely over the bulb (or sensor).
  • A "natural" WB temperature is obtained with no movement of air over the wick except that which occurs naturally in the environment.
  • Unventilated areas will have little air movement, while ventilated or outdoor areas will have more.
• Flag condition
  • Refers to a series of outdoor WBGT environments that provide ashore heat exposure or physical activity guidance to Navy and Marine Corps personnel.

The WBGT Index Flag Conditions:

• Green Flag (WBGT Index of 80°F to 84.9°F):
  • Heavy exercises for un-acclimated personnel shall be conducted with caution and under constant supervision.
  • Organized PT evolutions in boots and utilities are allowed for all personnel.
• Yellow Flag (WBGT Index of 85°F to 87.9°F):
  • Strenuous exercises, such as marching at standard cadence, shall be suspended for un-acclimated troops in their first 2 or 3 weeks.
  • Avoid outdoor classes in the sun.
• Red Flag (WBGT Index of 88°F to 89.9°F):
  • All physical training shall be halted for those troops who have not become thoroughly acclimated by at least 12 weeks of living and working in the area.
  • Those troops who are thoroughly acclimated may carry on limited activity not to exceed 6 hours per day.
• Black Flag (WBGT Index of 90°F and above):
  • All strenuous outdoor physical activity that is not essential (including organized or unorganized PT) mission accomplishment shall be halted for all units.