7. Outside (& Between) the Lines

The point we just made -- that drug crises contain similar elements which can be assessed and managed in similar ways -- is valid and useful, as far as it goes. But it's still only part of the picture, and only a general way of approaching drug emergency response. From here on out, we'll focus on specifics.

Because even though it may be helpful to see through the forest of details that inevitably surrounds a discussion of drug effects and emergency procedures, it can be absolutely vital to see a tree when it jumps right in front of you.

Among other "jumping trees" we'll be discussing in this section are drugs that hop over both classification lines and the response sets we proposed earlier. We will particularly emphasize life-threatening emergencies, such as aspirin and acetaminophen overdose and anticholinergic drug syndrome, which don't fit well into the CNS crisis model we proposed earlier.

That isn't meant to contradict what we've said thus far about the value of the CNS crisis continuum or the universal crisis response. Both are important tools for viewing the context and structure of crisis response.

If the earlier sections constituted the bare bones of drug crisis response, this chapter represents the skin and teeth and bones and hair.

Anticholinergic Drug Overdose Syndrome

Of all the exceptions to the CNS-arousal crisis model, perhaps the most distinctive is the toxic reaction produced by anticholinergic drugs.

These drugs, which include a variety of prescription and non-prescription medications based on the plant belladonna and its derivatives, are used to treat problems as diverse (and far-flung) as sinus congestion and irritable bowel syndrome. Other drugs having significant anticholinergic properties are the antidepressants.

The term anticholinergic itself refers to inhibition of the neurotransmitter acetylcholine, which is involved in the regulation of a number of body processes in the central and parasympathetic nervous system.

Why do anticholinergics figure so highly into drug emergencies? One reason is the sheer volume and variety of drugs with anticholinergic properties.

It's possible, for example, for a person taking one product for sniffles, say, and another for diarrhea and yet another for depression to be completely unaware of the risk of drug synergism.

Another reason is that antidepressants are prescribed to depressed people and depressed people sometimes try to kill themselves.

Any overdose involving drugs with anticholinergic properties should be regarded as a serious medical emergency. Symptoms can be tricky.

Both physiological and psychological effects can be determined by a number of factors, including drug type and dosage, interactions with other medications, route of administration, even user age and personality.

Similarly, symptoms can run the gamut, incorporating features that can be mistaken for both arousal-agitation and depressive-stupor emergencies.

In addition, a severe psychological syndrome can develop, particularly when the drugs are used with phenothiazine tranquilizers. Symptoms include auditory and visual hallucinations and toxic delirium.

When responding to anticholinergic drug emergencies, it's important to remember that a specific antidote, physostigmine, does exist for the syndrome. That's only one more reason EMS back-up is essential in resolving anticholinergic emergencies.

Anticholinergic Drug Crisis

Emotional component: Agitation, anxiety, confusion, delusions
Physiological signs: Dilated pupils, rapid or irregular heart beat, dry skin and mouth, flushed face, fever, abdominal pain, urinary retention, ringing in the ears, muscle spasms, coma
Behavioral signs: Disorientation, incoordination, impaired concentration, hallucinations.
Life-threatening complications: Convulsions, stroke, heart attack

Anticholinergic Drug OD Response

If the person is conscious:

Find out what drugs were taken and when.
Monitor vital signs.
Reduce stimuli.
Induce vomiting, if drugs were taken in past hour.
Call EMS, if necessary.

If the person is unconscious:

Check ABC's.
Call EMS.
If the victim is vomiting, place in recovery position.
Provide life-support and other emergency care.

Aspirin/Acetaminophen Emergencies

Aspirin and acetaminophen are main players in the drug crisis world, for reasons that might surprise you.

Acetaminophen (which is sold generically and under the brand names Tylenol™ and Datril™) was the fourth-most common drug mentioned in U.S. emergency room admissions during 2000 (figuring into 33,613 emergencies), while good old-fashioned aspirin was right behind, in the fifth spot, helping to land 15,657 folks in the hospital.


A main reason is that both drugs are often combined with other more-potent analgesic and psychoactive drugs, like codeine (in Empirin™ or Tylenol™ #1, 2, 3, and 4), oxycodone (Percodan™, Percocet™), and even barbiturates (Fiorinal™).

One result for users can be dependence on the psychoactive component and overdose on the acetaminophen or aspirin. And that can be a real problem, particularly since each of the non-prescription painkillers can trigger a life-threatening overdose syndrome.

A special danger of acetaminophen involves the mildness of symptoms after an overdose. Symptoms may go unnoticed for up to two days after an overdose, before serious problems emerge due to cumulative toxic effects on the liver.

At high risk for both types of overdose are older people, who can come to rely on either or both of the drugs for pain management:

Overdose can occur with as little as one or two tablets above an ordinary tolerated dose, when a regular user crosses his or her "metabolic threshold."

A specific antidote, N-acetylcysteine, exists for acetaminophen OD when administered in the first 10 hours of overdose, making quick assessment and response -- and quick action (and movement in the direction of a hospital emergency room) -- vital.

Aspirin Overdose

Emotional component: Confusion, fatigue, anxiety
Physiological signs: Headache, ringing in the ears, dim vision, sweating, thirst, rapid breathing, nausea, vomiting, abdominal pain, skin eruptions, convulsions, coma
Behavioral signs: Incoherent speech, delirium, hallucinations
Life-threatening complications: High body temperature, dehydration, respiratory failure, heart attack

Aspirin OD Response

If the person is conscious:

  • Find out what drugs were taken and when.
  • Induce vomiting, if drugs were taken in past hour.
  • Monitor vital signs.
  • Reduce body heat, if excessive, by applying wet towels, etc.
  • Call EMS, if necessary. Crisis symptoms can develop quickly.

If the person is unconscious:

  • Check ABC's.
  • Call EMS.
  • If the victim is vomiting, place in recovery position.
  • Reduce body heat, if excessive, by applying wet towels, etc.
  • Provide life-support and other emergency care.

Acetaminophen Overdose

Emotional component: Unease, anxiety, emotional distress
Physiological signs: Nausea, vomiting, pallor, profuse sweating, skin rash, fever
Behavioral signs: Delirium, unconsciousness
Life-threatening complications: Liver and kidney damage, hypoglycemic coma

Acetaminophen OD Response

If the person is conscious:

  • Find out what drugs were taken and when.
  • Monitor vital signs.
  • Induce vomiting, if drugs were taken in past hour.
  • Call EMS, if needed.

If the person is unconscious:

  • Check ABC's.
  • Call EMS.
  • If the victim is vomiting, place in recovery position.
  • Monitor vital signs.
  • Provide life-support and other emergency care

Inhalant Overdose & 'Sudden Sniffing Death'

Of all the drugs that strain the CNS-arousal emergency model, perhaps the group that's most immediately lethal is the inhalants, particularly volatile solvents ("volatile" means they change from liquid to gas when exposed to air) and aerosols.

Inhalants can get you in a couple of ways.

Probably the best-known way is the syndrome known as "sudden sniffing death," or SSD.

SSD typically follows a consistent pattern: After sniffing to the point of intoxication, a user is suddenly surprised or abruptly begins a strenuous activity -- running at top speed, for example, or lifting a heavy object.

Physical collapse and death frequently follow, usually due to severe cardiac arrhythmia.

Besides SSD, inhalants can also cause a variety of other serious problems:

  • Freon can cause suffocation in the form of "airway freezing," as the refrigerant vaporizes in the throat.
  • Industrial solvents can cause a number of problems related to their toxicity, including irreversible organ damage.
  • Deaths can also result from the inhalation of various solvents (including naptha, benzene, acetones, and others) or when users pass out with solvent-soaked plastic bags still covering their nose and mouth.

Psychological effects of inhalants can also be perplexing, with excited, agitated behavior sometimes giving way rapidly to profound CNS depression.

Still, from a crisis perspective, the most distinctive element of an inhalant OD is its speed of onset.

Rapid response is the only way to even the odds.

Inhalant Overdose

Emotional component: Excitement, euphoria, disorientation, depression
Physiological signs: Headache, ringing in the ears, double vision, dilated pupils, increased heart rate, irregular heartbeat
Behavioral signs: Slurred speech, incoordination, increased activity, slowed reflexes, unconsciousness, delusions, hallucinations
Life-threatening complications: Sudden sniffing death, behavioral toxicity (sometimes brought on by impulsive, hazardous actions)

Inhalant Overdose Response

If the person is conscious:

  • Find out what chemicals were inhaled and when.
  • Monitor vital signs.
  • Call EMS, if needed.

If the person is unconscious:

  • Check ABC's.
  • Call EMS.
  • Remove rags, bags, or other sources of toxic fumes.
  • Monitor vital signs.
  • Provide life-support and other emergency care.

PCP/Ketamine Emergencies

The last drug group that we'll focus on that significantly deviates from our agitation-stupor continuum is phencyclidine, or PCP, and its chemical cousin, ketamine (commonly known as "K" or "Special K").

Developed and used medically as animal tranquilizers and surgical anesthetics, they deserve special consideration because each combines wildly varying, even contradictory, effects in a single pharmacological package.

Depending on dosage and personality characteristics of the user, both PCP and ketamine can produce effects that mix -- in the same episode -- stimulant, anesthetic, hallucinogenic, and depressant properties. In addition, both drugs can trigger bizarre psychological effects, including depersonalization, delusions, and visual and auditory hallucinations.

Effects are dose-related, meaning that higher doses cause more intense and more dangerous physical and psychological effects. Still, since both drugs are depressants, it's important to bear in mind that both react synergistically with other CNS depressants (including alcohol), which can lower overdose threshold and raise overdose risk.

Effective crisis response must involve a careful reading of the user's behavioral and emotional state and physiological symptoms.

Paranoia and delusional thinking can so distort personality as to pose a physical risk to the crisis helper. For this reason, do not attempt to enter a user's personal space without being invited.

Stay calm and demonstrate relaxed self-control with a psychologically-distraught user, but call for EMS back-up if obviously psychotic ideation or dangerous behavior persists.

PCP/Ketamine Overdose/Agitation Response

Emotional component: Excitement, agitation, anxiety, disorganized thought, paranoia, terror
Physiological signs: Blank stare, flushing, vomiting, convulsions, increased heart rate, rapid and shallow breathing, involuntary rapid eye movements
Behavioral signs: Incoherence or inability to speak, incoordination, fever, decreased reflexes and sensitivity to pain, hallucinations, delusions, hostile or violent behavior
Life-threatening complications: Convulsions, stroke, respiratory failure, behavioral toxicity

PCP/Ketamine Crisis Response

If the person is conscious:

  • Establish a friendly relationship.
  • Ask for permission to help.
  • Reduce stimuli.
  • Reassure person that he/she is experiencing the effects of a drug that will wear off soon.
  • Call EMS, if needed.

If the person is unconscious:

  • Check ABC's.
  • Call EMS.
  • Monitor vital signs.
  • Provide life-support and other needed care.

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