Providing comprehensive prehospital care to overdose patients
Medic 3 arrives on scene to find a 36-year-old male patient supine on the living room floor. The patient is in respiratory arrest and fire department first responders are providing rescue breaths with a bag-valve mask (BVM). The patient has a bounding carotid pulse. A nasopharyngeal airway is placed in the patient’s left nares and the patient is ventilated easily with adequate bilateral lung sounds.
The floor is bare wood and the patient is only wearing light undergarments. The ambient temperature in the room is approximately 55 degrees F. The patient’s roommate states that he last saw the patient approximately six hours ago. The crew notes that the patient’s pupils are pinpoint and there is drug paraphernalia surrounding the patient. There is no evidence of trauma.
Assessment of the patient’s vital signs reveals a heart rate of 123 beats per minute, blood pressure of 122/86 mmHg, and an oxygen saturation of 98% with assisted ventilation (his room air oxygen saturation was 66%). His initial end tidal CO2 is 70 mmHg and his blood glucose is 269 mg/dL. The patient’s skin is pale, dry and cold to the touch. After establishing IV access and starting a normal saline bolus, the crew administers 0.4 mg of IV naloxone (Narcan).
After five minutes, his spontaneous respiratory effort improves and he becomes agitated and combative. The patient’s movement isn’t purposeful and he isn’t able to speak. The patient is placed on high flow oxygen via non-rebreather mask. Reassessment of vital signs reveals a heart rate of 140 beats per minute, a blood pressure pf 134/83 mmHg, a SpO2 of 99%, a respiratory effort of 30 breaths per minute, and an EtCO2 of 34 mmHg. The patient now has a Glasgow coma score of 8.
One of the first responders suggests an additional dose of naloxone because the patient is still obtunded. Though the patient continues to exhibit decreased mentation, he’s breathing adequately, so there’s no indication to give additional naloxone. The crew captures an ECG which is unremarkable and prepares the patient for transport to the hospital.
While en route to the receiving facility, the patient becomes increasingly combative and the crew is forced to sedate him with midazolam (Versed). After two 2.5 mg of IV midazolam, the patient is appropriately sedated. The patient doesn’t experience any respiratory depression and the rest of the transport is uneventful.
Upon arrival at the ED, the patient is transferred to staff, and the crew starts to get their gear back together for the next call. The patient’s urine drug screen is found to be positive for opioids as well as cocaine, and his core body temperature is 84 degrees F. Active rewarming is initiated in the ED and the patient is admitted to the ICU. A CT scan of the patient’s brain reveals evidence of anoxic brain injury and his prognosis is unclear.
Presumably, the patient overdosed on heroin, experienced respiratory depression with a prolonged period of hypoxia, as well as significant hypothermia after being immobile on the cold floor for approximately five hours.
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