6. Response Sets: Arousal & Stupor
One way of looking at drug emergencies
is to focus on their differences. And to be sure, there are a
lot of those. But looking at differences, it's easy to be overwhelmed
by details. Just trying to sort out all the new names for drugs
on the street -- "ice" and "crack" or "squeeze"
and "wack" -- can turn into a full-time job.
And forget all the new prescription drugs that appear -- the
Prozacs and Xanaxes and Viagras, the ones that sweep into medical
journal ads one year and into patients' lives and emergency rooms
the next.
Each one comes with a package insert that could choke a police
dog, listing contraindications and adverse reactions and overdose
treatment suggestions.
And if you think you have to know all of that and everything
else there is to know about drugs to be useful in an emergency,
there aren't going to be enough crisis helpers to go around --
not by a long shot.
That's why we think it makes more sense, in discussing short-term
crisis response, to focus on the similarities of drug crises.
Viewed from this perspective, it's more important to reduce the
number of variables than to split hairs trying to delineate differences
between drugs and drug groups that produce generally similar
sets of response.
Put in everyday terms, this means that it doesn't matter all
that much whether an unconscious person is overdosed on Nembutal
or alcohol or codeine -- at least not from the viewpoint of making
a fast assessment, getting EMS support, and performing needed
short-term life support.
By the time you get the person to a hospital emergency room,
it'll make all the difference in the world. But at the crisis
scene, the distinctions are less meaningful, since each of the
above OD's can be deadly and all can be managed in similar ways.
Don't think this means that the distinctions between different
groups of drugs are irrelevant -- far from it. A Valium or Xanax
OD is almost always less lethal than a barbiturate OD. It simply
means that our role in dealing with an unconscious victim is
to respond to what we see and manage what's there.
And we begin to do that best when we eliminate unnecessary distinctions
and streamline the response process.
In this chapter, we're going to do just that, by reducing the
entire spectrum of drug emergencies to two basic types: arousal-agitation
and depressive stupor.
From there, we're going to be looking for commonalties that apply
to all drug emergencies of whatever type. Because the fact is
that they're the same in as many ways as they're different.
CNS Arousal Continuum
Viewed in this way, it's possible
to see psychoactive drug effects as points on a continuum of
consciousness, reflecting levels of central nervous system (CNS)
arousal.
This is not meant to imply that psychoactive drugs only produce
CNS arousal or depression -- that's plainly untrue. There are
simply too many exceptions -- hallucinogens, anti-depressants,
inhalants, and others -- for this model to apply to anything
more general or specific than crisis response.
But it's useful for our purposes, for the simple reason that
drug crisis reactions conform more closely to a bipolar model
than do individualized non-crisis drug reactions and because
CNS activity -- although not the only site of drug action or
the only important index of drug toxicity -- covers most of the
territory we need to consider at this level of analysis.
So what, then, are the bipolar "caps" of our hypothetical
two-crisis world?
At one extreme is a state of CNS hyperarousal, or agitation.
It ends in death, usually from heart failure.
At the other extreme is hypoarousal, or CNS depression and stupor.
It often terminates in death from respiratory collapse.
All drugs push the user up or down, in one way or another, along
this continuum. And the outer limits of the continuum always
mean trouble, life-threatening trouble.
General Response Groups
Signs & Symptoms
The signs and symptoms of the
two main drug crisis states are as different as the drug groups
and individual drugs within the groups that inspire them.
Symptoms of arousal-agitation states are intensified, high-amplitude
variations on the basic CNS-stimulant drug theme.
Prototype drugs for the class (and the crisis state) are amphetamines
and cocaine -- including each drug's smokable form, "glass"
(or "ice") and "crack" -- which, not uncoincidentally,
are two of the main instigators of drug emergencies in the early
21st Century.
Symptoms and complications can range from the very mild to the
very severe; problems can vary, on the emotional side, from ordinary
nervousness to full-blown psychotic states. On the physical side,
effects can swing from mildly elevated heart beat to complete
cardiovascular collapse.
Arousal/Agitation Emergency
Emotional component: Anxiety, panic, feelings of unreality.
Physiological signs: Rapid breathing, breathlessness,
rapid pulse, dilated pupils, excessive body heat
Behavioral signs: Restlessness, apprehension, emotional
upset
Life-threatening complications: Convulsions, stroke, heart
attack
On the other side of the continuum,
the depressive-stupor crisis state is triggered by drugs whose
primary action is depression of the central nervous system: narcotics,
sedative-hypnotics, tranquilizers, and alcohol.
Depressive-Stupor Crisis
Emotional component: Depression, lassitude, lethargy
Physiological signs: Reduced or irregular breathing, slow
pulse
Behavioral signs: Slurred speech, impaired motor control,
slowed reflexes
Life-threatening complications: Respiratory failure, heart
attack
General Response
Groups: Intervention Procedures
Arousal/Agitation Response
If the person is conscious:
Establish a relationship. Ask
for permission to help.
Find out what drugs were taken and when.
Reduce stimuli as much as possible: Turn down music and bright
lights; ask passersby or onlookers to leave; move the person
to a quiet place.
Reassure the person that the effects he or she is experiencing
are caused by a drug and that they will wear off.
Demonstrate by actions and attitude that you're relaxed and in
control.
Stay with the person until he/she regains control and drug effects
have ended.
If the person is unconscious:
Check ABC's.
Call EMS.
Monitor vital signs.
Provide life-support or other emergency care.
Depressive-Stupor
Response
If the person is conscious:
Establish a relationship. Ask
for permission to help.
Find out what drugs were taken and when.
If the amount taken is significantly more than a prescribed dose
or is enough to arouse your concern, keep the person awake and
moving and call EMS.
If the drugs were taken in the past hour, suggest that the person
induce vomiting by sticking his or her finger down throat or
by taking syrup of ipecac or activated charcoal, if available.
If the person is unconscious:
Check ABC's.
Call EMS.
If the person is vomiting, or you suspect he or she might, move
him/her into the recovery position.
Monitor vital signs.
Provide life-support or other emergency care.
Universal
OD Response
Now that we've set some general
parameters for an arousal-depression, crisis-continuum worldview,
we'll take things a step further, and propose a single, general
set of principles that apply to every overdose emergency.
The guidelines are simple, but reasonably comprehensive.
They touch on everything we've talked about thus far, and will
even expand to include specific recommendations that we'll make
in the chapters to follow.
The recommendations below apply to all drug overdoses involving
an unconscious victim:
- Check ABC's.
- Move the person into the Recovery
Position, if vomiting.
- Call EMS if the victim displays
any of the following:
- problems breathing (respirations
below 8 or above 20 per minute);
- is unconscious and cannot be
roused;
- vomiting while unconscious or
semi-conscious;
- pulse is above 120 or below
60 per minute;
- Provide life support or emergency
care.
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