Notes – Stimulant Poisoning/Overdose

Stimulant Poisoning/Overdose

Patient Safety Considerations

  1. Apply the least amount of physical management devices that are necessary to protect the patient and the providers [see Agitated or Violent Patient/Behavioral Emergency guideline]
  2. Assessment for potential weapons or additional drugs is very important since these items can pose a threat not just to the patient but also to the EMS crew

Notes/Educational Pearls

Key Considerations

  1. Recognition and treatment of hyperthermia (including sedatives to decrease heat production from muscular activity) is essential as many deaths are attributable to hyperthermia
  2. If law enforcement has placed the patient in handcuffs, this patient needs ongoing physical security for safe transport. Have law enforcement in back of ambulance for the handcuffed patient or make sure proper physical management devices are in place before law enforcement leaves and ambulance departs from scene
  3. If patient has signs and symptoms of ACS, strive to give nitroglycerin SL every 3 minutes as long as SBP greater than 100 mmHg and until pain resolves
    1. Vasospasm is often the problem in this case as opposed to a fixed coronary artery lesion
    2. Consider administration of benzodiazepines as if to treat anxiety.
  4. Maintaining IV access, cardiac monitor, and SPO2/ETCO2 monitors are key to being able to catch and intervene decompensations in a timely manner
    1. If agitated, consider restraining the patient to facilitate patient assessment and lessen likelihood of vascular access or monitor displacements

Pertinent Assessment Findings

  1. History is as important as the physical examination.
  2. If the patient is on psychiatric medication, but has failed to be compliant, this fact alone puts the patient at higher risk for excited delirium
  3. If the patient is found naked, this may elevate the suspicion for stimulant use or abuse and increase the risk for excited  Neuroleptic malignant syndrome, serotonin syndrome and excited delirium can present in with similar signs and symptoms
  4. If polypharmacy is suspected, hypertension and tachycardia are expected hemodynamic findings secondary to increased dopamine release. Stimulus reduction from benzodiazepines, anti-psychotics, and ketamine will improve patient’s vital signs and behavior
  5. Be prepared for the potential of cardiovascular collapse as well as respiratory arrest
  6. If a vasopressor is needed, epinephrine is recommended

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914225 – Medical-Stimulant Poisoning/Overdose

Key Documentation Elements

  • Reason for psychologic and physical management procedures used and neurologic/circulatory exams with device use.
  • Reason for medications selected
  • Documentation of QT interval when antiemetic medications, haloperidol, or droperidol is used and result conveyed to ED staff

Performance Measures

  • Recognition and treatment of hyperthermia
  • Recognition of need for monitoring cardiovascular and respiratory status of patient with stimulant toxicity
  • ACS evaluation and treatment considered for chest pain and shortness of breath
  • Respiratory compromise quickly recognized and treated
  • Cardiovascular compromise quickly recognized and treated
  • Patient and medics did not suffer any harm
  • Access and monitoring were not lost during transport