5. Physical Intervention: Life Support

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 immediately serious.

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 for granted.

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.

Breathing Emergencies

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.

Rescue Breathing

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 nostrils shut.

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 5-10 seconds.

If the victim still isn't breathing, but does have a pulse, resume rescue breathing.

If there is no pulse, begin CPR.

Special Problems

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 is vomiting.

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.

Cardio-Pulmonary Resuscitation

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 stopped.

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 victim.

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 technique.

For a review of specific CPR procedures, please refer to the accompanying text and illustrations on page 22.

Other Skills

Inducing Vomiting

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 own.

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 starts.

Recovery Position

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 side.

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 airway.

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 leg.

Pull gently on the left thigh and shoulder until the person is lying face down, with the head turned to one side.

Check ABC's.

Other Problems

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.

Coma

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.

Convulsions

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.

Diabetic Emergencies

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.

Shock

Definition: Physical collapse caused by inadequate blood flow to body tissues.
Types: Anaphylactic, hypoglycemic, insulin, traumatic, etc.
Causes: Trauma, including heart attack, allergic reaction, burns, infection, sudden blood loss, dehydration, drug reaction or poisoning.
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.

Read On! Click to continue...

This is one in a series of publications on drugs, behavior, and health published by Do It Now Foundation.
Please call or write for a complete list of available titles, or check us out online at
www.doitnow.org.