5. Physical Intervention:
No matter what other problems
may arise in a drug-related emergency, heart and respiratory
failure are two of the most obvious and certainly the two most
Biological thunder and lightning that strike suddenly and without
warning, heart attack and respiratory failure are the main causes
of death in drug crises.
Irregular heartbeat and heart failure can follow cocaine and
amphetamine use, as well as use of other drugs, including anti-depressants
and inhalants (in a syndrome known as "sudden sniffing death"),
while respiratory collapse is often linked to overdoses of narcotics,
barbiturates, alcohol, and other depressants.
That's why we stress the physical management techniques in this
chapter so much. They're simply too indispensable to be taken
Still, we need to emphasize that the information in this section
isn't intended to replace actual training and periodic refresher
courses offered by the Red Cross or other groups. It's meant
for review purposes only.
CPR, in particular, can create life-threatening problems if performed
incorrectly or if attempted on someone who doesn't need it.
So if you haven't received hands-on training in CPR, artificial
respiration, or other first-aid techniques, get it. Contact a
local branch of the American Red Cross.
They'll tell you how to register for training in your area.
There are three basic ways in
which breathing can stop in a drug emergency:
directly, by direct drug action on brain breathing centers
(particularly in the case of depressant overdoses), or
indirectly, by blocking the airway (especially
through aspiration of vomitus), or through the
'behavioral toxicity' of risky or unsafe actions (e.g. swimming,
and drowning, while high)
But no matter what causes breathing
to stop, causing it to start again is always the first priority
in a crisis. Permanent brain damage or death can result when
the brain is deprived of oxygen for as little as 4-6 minutes.
Fortunately, artificial respiration (or rescue breathing, as
it's also known) is a skill that's easily learned and always
available. The procedures flow directly from the ABC's of the
primary survey, discussed in the last chapter.
The basic premise of rescue breathing
is simple enough.
The air we breathe in is about 21 percent oxygen and the air
we breathe out is about 16 percent oxygen. That means there's
more than enough oxygen left over to keep someone else alive
in an emergency. Rescue breathing is the technique that gets
it to them.
If you discover in the primary survey that a person is not breathing
and requires life support, start by rolling the victim onto his/her
back, if necessary.
Make sure the airway is open and check for and remove any obvious
obstructions in the mouth (gum, dentures, vomitus, or other fluids).
Position your ear over the person's nose and mouth, and check
for breathing for 3-5 seconds. If there's no breath, pinch the
Then take a deep breath, open your mouth wide, and form a seal
with your lips around the person's mouth.
Exhale for 1-1.5 seconds, which should be enough to make the
person's chest rise. Pause between rescue breaths to inhale.
Then look, listen, and feel for chest movements or the sound
of escaping air.
If you don't detect breathing, re-check the carotid pulse for
If the victim still isn't breathing, but does have a pulse, resume
If there is no pulse, begin CPR.
Although rescue breathing is
a fairly simple technique, you need to be careful not to force
air into the person's stomach.
Air in the stomach can cause vomiting, which raises the risk
of a different type of potentially-lethal problem -- aspiration
of vomit fluids into the lungs.
To avoid breathing air into the stomach, the Red Cross recommends
the following safeguards:
Make sure the person's head is tilted all the way back.
Don't force too much air into the victim's lungs. Breathe in
only enough to make the chest rise.
Pause to let the victim's lungs empty between breaths.
Another special problem that can arise during rescue breathing
If this happens, quickly tilt the person's head and body to the
side. Afterwards, wipe away any vomited material, and resume
rescue breathing, if necessary.
CPR, or cardio-pulmonary resuscitation,
is a life-support technique aimed at re-establishing heart beat
and respiration in a person whose heart and lung functions have
CPR builds on the basic processes of the primary survey and rescue
breathing, and should be undertaken only if both breathing and
pulse are absent, as determined in the primary survey.
To administer CPR, a rescuer kneels beside the victim, and performs
a single cycle (two full breaths and a check for carotid pulse)
of rescue breathing. Then, if no pulse is present, he/she places
the heel of one hand over the lower part of the victim's sternum
(or breastbone), 1-1.5 inches from its tip, puts the other hand
over the first and positions the shoulders squarely over the
The rescuer then presses down forcefully and rhythmically onto
the sternum for a count of 15 compressions (at a rate of 80-90
compressions per minute), before going back to the rescue breathing
cycle, and checking carotid pulse. If the pulse returns, the
rescuer continues to check for breathing.
If breathing resumes, he/she checks ABC's. If neither pulse nor
breathing resumes, the rescuer continues CPR.
To reduce the risk of CPR-related problems, the Red Cross makes
the following recommendations:
Don't perform CPR on a person who has a pulse, no matter how
weak or slow. If a victim with a slight or irregular pulse is
not breathing, perform rescue breathing. If the person is breathing,
continue to monitor ABC's.
Don't waste time removing clothing from a victim's chest area
unless the clothing prevents you from establishing the location
for chest compressions.
Perform CPR only on a hard, flat surface. If the victim is in
bed, move him or her to the floor, before beginning the procedure.
As we pointed out earlier, CPR should be performed only by persons
trained and certified by the American Red Cross. Because of its
inherent dangers, it should be considered a last-resort life-support
For a review of specific CPR procedures, please refer to the
accompanying text and illustrations on page 22.
Although induced vomiting has
long been a standard ER response to oral drug overdose, the value
of the practice is currently up in the air.
Why? For a couple of reasons.
For one, syrup of ipecac (a substance often used to promote vomiting)
doesn't seem to work that well at removing drugs from the stomach.
For another, ipecac-induced vomiting and gastric lavage (stomach
pumping) each can cause significant health problems of their
And for yet another other reason, often by the time ER's (or
crisis workers, for that matter) come into contact with OD victims,
the drugs may have been in their stomachs for hours.
Those are three reasons that activated charcoal is now being
promoted as a better alternative to ipecac in cases of overdose
or drug poisoning.
According to recent studies, charcoal is better adapted at blocking
drug absorption than vomiting, so much so that some experts recommend
that activated charcoal be "routinely administered"
in all ER admissions involving possible drug overdose.
Still, we think it's good advice to induce vomiting if pills
were recently taken (within the past hour or so).
Best bet: If the victim is still fully conscious, get him or
her to induce vomiting, either by tickling the back of the throat
or by taking syrup of ipecac. Precautions:
Never induce vomiting if person
is semiconscious or comatose. Don't induce vomiting if drug(s)
were smoked, injected, or inhaled. And if you use syrup of ipecac
to induce vomiting, don't administer charcoal before vomiting
Another serious problem that
arises in drug emergencies is the risk of vomiting while unconscious
or semi-conscious and choking on the aspirated vomit fluid.
Because of the danger this represents and the frequency with
which it kills, it may become necessary to place a semi-conscious
person into the so-called "recovery position," if the
person begins to vomit or if, for any reason, it becomes impossible
for you to continuously monitor the airway.
An unconscious person should
only be moved into the recovery position if you're sure
there's no serious injury to the neck or spine.
To move someone into the recovery
position, simply kneel at their side and turn the head to the
Gently lift up on the thigh and
shoulder and carefully roll the victim onto the abdomen, with
the face to one side.
Continue to maintain and monitor
If the person's body size makes
movement difficult, try the following:
Kneel at the person's right.
Turn the head to the right, maintaining airway.
Tuck the right arm under the
right buttock, place left arm across chest.
Cross the left leg over the right
Pull gently on the left thigh
and shoulder until the person is lying face down, with the head
turned to one side.
A variety of other physical problems
can also arise in a drug crisis that are no less life-threatening
than heart or respiratory problems.
Most of these conditions involve the "red flag" symptoms
we discussed in the last chapter. The problems themselves --
including shock, coma, and convulsions -- may involve physical
responses to drug toxicity or may arise completely apart from
drug use, and can be mistaken for drug emergencies.
Still, no matter how they arise, each represents a potentially
life-threatening emergency and should be regarded as such. Standard
assessment and life-support techniques apply regardless of the
origin of the problem. And remember that not all symptoms listed
may be present in any given situation.
Definition: Abnormal stupor caused by injury or
illness in which the person cannot be aroused by external stimuli.
Causes: More than half of all cases are caused by injury
or impaired blood flow to the head and brain (e.g. hypertension,
tumor, fever, infection, hemorrhage, drugs).
Types: Alcoholic, apoplectic (caused by stroke, results
in paralysis to one side of the body), diabetic (caused by lack
of insulin and which may be confused with hypoglycemic coma),
uremic (caused by impaired kidney function; results in build-up
of toxic body waste products).
Management: Do not move patient; may exacerbate head injury.
Loosen collar. Apply cool compresses to forehead if person is
feverish. Monitor ABC's. Call EMS.
Definition: Sudden, involuntary muscular spasms,
often violent. Seizures often involve loss of consciousness.
Causes: Seizures can occur as a result of drug withdrawal
and poisoning. Other factors: epilepsy, diabetes (low blood sugar),
high fever (especially in children), brain tumors, head injuries.
Drug factors: Amphetamines can cause convulsions. Seizures can
occur during withdrawal from alcohol or other depressants, usually
within a day or two of the time use was stopped.
Symptoms: The person may lie rigid for a few seconds before
convulsing. Seizures usually last about a minute.
Management: Reduce stimuli, if possible. Lay the person
down. Cradle his/her head and neck, if possible, to prevent head
injuries. Goal: Keep the person from biting his/her tongue, suffocating,
or causing self-injury. Move away furniture or other objects
that could cause injury. Don't attempt to stop convulsion by
restraining the person, which may cause injury.
After seizures: Check ABC's; examine the person for injuries.
If breathing has stopped, check to see if the tongue is blocking
the airway. If not, perform rescue breathing.
Definition: Any major problem involving shock, unconsciousness,
or coma arising from diabetes or related complications.
Types: Insulin reaction, diabetic coma.
Causes: Too much insulin and too little blood sugar available
to brain (insulin reaction); insulin insufficiency (diabetic
coma). Diabetic coma can be caused by eating too much sugar,
stress, or infection. Insulin reaction can be caused by an insulin
overdose or other factors.
Symptoms: Insulin reaction: Rapid, shallow breathing and
pulse; dizziness; sweating; headache; numbness in extremities;
unconsciousness. Diabetic coma: Rapid, deep breathing; sleepiness;
confusion; thirst; dehydration; fever; sweet-smelling breath.
Management: Give juice, candy, or sugar. This will help
reverse an insulin reaction, but will not harm someone in a diabetic
coma. If unconscious, check ABC's and call EMS.
Definition: Physical collapse caused by inadequate
blood flow to body tissues.
Types: Anaphylactic, hypoglycemic, insulin, traumatic,
Causes: Trauma, including heart attack, allergic reaction,
burns, infection, sudden blood loss, dehydration, drug reaction
Symptoms: Pale skin, blue or gray discoloration, weak
and rapid pulse, irregular (esp. fast and shallow or deep and
uneven) breathing. If conscious, a person in shock may seem excited
and disoriented, have glassy eyes, be oblivious to pain, and
be extremely thirsty.
Management: Help the person lie down, with head lower
than body. Elevate the lower extremities by propping on pillows.
Keep the person warm, but not hot. Reduce stimuli.
Treat any seriously injured person
for shock to keep them from going into shock. Even though he/she
may complain of thirst, discourage excessive drinking to reduce
the risk of unconscious vomiting. Emotional support and gentle
handling are also important.
Due to their similarity to drug emergencies, it's not uncommon
for any of the above conditions to be confused with a drug overdose.
That's why we emphasize the need for responding to what you see
rather than what you might think.
Sometimes, there's a world of difference between the two.