• Case Study #1: Heroin overdose

    by Alan Batt. Last modified: 28/02/14

    ivdu1

    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.

    History

    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

    Clinical Impression

    1. Respiratory Depression secondary to heroin overdose
    2. 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.

    Secondary Survey

    AMPLE History

    • 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

    Pre-hospital management

    OPA inserted and tolerated. O2 @15lpm commenced. Naloxone 800mcg IM. Sterile dressings placed over burns. Transported to ED.

    In-hospital management

    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

    Learning Outcomes

    Heroin (Opiate)

    • 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)

    References (non-PubMed)

    • 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

    References

     
    1.

    Warner-Smith M1, Darke S, Day C. Morbidity associated with non-fatal heroin overdose. Addiction. 2002 Aug;97(8):963-7. PMID: 12144598.

     
    2.

    Dettmer K1, Saunders B, Strang J. Take home naloxone and the prevention of deaths from opiate overdose: two pilot schemes. BMJ. 2001 Apr 14;322(7291):895-6. PMID: 11302902.

     
    3.

    Bazazi AR1, Zaller ND, Fu JJ, Rich JD. Preventing opiate overdose deaths: examining objections to take-home naloxone. J Health Care Poor Underserved. 2010 Nov;21(4):1108-13. PMID: 21099064.

    The following two tabs change content below.
    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

    Tags: , , , ,

    2 thoughts on “Case Study #1: Heroin overdose

    • @Cannulator says:

      So what analgesia for their burns in hospital? At least for the partial thickness burns, and areas surrounding full thickness ones.
      Despite the obvious effect fo the heroin and the accepted Mx of naloxone- I wonder if in some ways it’s facilitates airway management/analgesia until at ED and then let them sort it. Obviously countering hypoxia with O2 and ventilation as above.

      • Alan Batt Alan Batt says:

        To be honest, the analgesia choice in the burn unit isn’t known for this patient. But I’d imagine opioids featured at some stage again post-infusion of naloxone. In the meantime, ketamine might be a good choice? Your thoughts?

        The myth of full-thickness burns not having pain is just that – many of these patients will not complain of sharp pains, but many complain of deep aching pains related to the inflammatory process. And of course as you said, the transition zone is nearly always acutely painful.

    Leave a Reply