Drug Overdose

DR., Dr. Nicolaski Lumbuun, SpFK

 Learning Objective
• Describe the definition of drug overdose
• Recognize the general symptoms of drug overdose
• Describe the important examination of drug overdose
• Describe the etiology & patho/physiology of drug
overdose
• Describe the algorithm of management for patient with
drug overdose
• Determine diagnosis of causes drug’s overdose
• Able to early treatment & giving a referral to specialist
 Definition
 a Drug : any substance that in small/limited amounts
produces significant changes in the body, mind or both.
 an Overdose : when an individual takes more of a drug
or combination of drugs than the body can handle.
 In particular, overdose occurs when certain vital organs
get overwhelmed, including: Lungs, heart, liver, kidneys
& brain
 When or Why it happen ???
• Can be either accidental or intentional
• Quality of the drug  relatively toxic drugs = narrow
angle therapeutic level
• Quantity of the drug or drugs (drugs interaction)
• More sensitive to certain medications
• Mode of administration
• Policy factors unclear of the uses direction
 Epidemiology Data
• WHO : >1/2 of all medicines are prescribed, dispensed
or sold inappropriately, and that half of all patients fail
to take them correctly
• Every day in the US, 114 people die as a drug overdose, & 6,748
are treated in emergency for the misuse/abuse
• In 2012, 33,175 (79.9%) of the 41,502 drug overdose deaths were
unintentional, 5,465 (13.2%) were of suicidal intent, 80 (0.2%)
were homicides, and 2,782 (6.7%) were of undetermined intent
• In Indonesia, there is a lack of data
 Recognizing of drug Overdose
Type of Drug overdose :
• Due to medication, eg. sensitivity to certain drug,
drugs interaction
• Drugs abuse illicit drugs that used to get high,
may be taken became overdose
• Exposure to chemicals, plants, and other toxic
substances, eg. OP, CO poisoning & mushroom
poisoning
 Early Detection & Identification
 The symptoms of overdose can be fatal wo/ intervention!
 The RESPONSE to an Over Dose is critical!
 Overdose death CAN BE PREVENTED!

Who’s At Risk?
Everyone who uses drugs
Any period of abstinence
Release from prison or jail
Any major life transition/major disappointment
Family conflict
 General Symptoms
• Awake, but unable to • Throwing-up
talk • Passing out
• Body is very limp • Choking sounds, or a
• Face is very pale gurgling noise
• Pulse is slow, erratic or • Breathing is very slow
not there at all and shallow, erratic or
has stopped
 Specific Symptoms of Opiate Overdose
Moderate Serious
• Uncontrollable nodding • Awake - unable to talk
• Inability to focus • Body is very limp
• Excessive drooling • Erratic or very shallow
• Pale skin color breathing
• Incoherent speech • Excessive vomiting
Severe
Unconscious Lying in vomit
Change in skin color Choking or gurgling
Difficulty of breathing Pulse is shallow/erratic
Specific Symptoms of Stimulant Overdose
Moderate Serious
o Incoherent speech o Inability to focus
o Extreme paranoia o Vomiting
o Pale skin o Foaming at mouth
o Jaw/teeth clenching o Tightness of chest
o Aggressiveness o Unable to talk
o Minor Tremor
o Unable to walk
o Excessive sweating
o Clammy skin
o Erratic pulse
o Very rapid pulse o Violent actions
Severe
Seizures Difficulty of breathing
Unconsciousness Erratic pulse
Choking/gurgling
 Specific Symptom of alcohol over dose
• Determine of Blood Alcohol Concentration/Level (BAC/BAL)
– BAC 0.02-0.03 (=20-30mg/dL)slight euphoria, loss of shyness
– BAC 0.04-0.06  Feeling high (epuhoria) with relaxation, a sensation of
warmth, lowered caution, minor impairment of reasoning and memory
– BAC 0.07-0.09  slight impairment of balance, speech, vision, and
hearing. Reduced judgment and self-control.
– BAC 0.08  being legally intoxicated (binge drinking)
– BAC 0.1-0.125  significant impairment of motor coordination and loss
of judgment, slurred speech, impaired balance, vision
– BAC 0.13-0.15  gross motor impaired, lack of physical control
– BAC 0.25  need assisstence in walking, total mental confusion,
dysphoria, nausea-vomiting.
– BAC 0.3  loss of conciousness followed by coma, >0,4 death due to
respiratory arrest
Specific Symptom of canabis over dose
o Sign :  Symptoms :
 Euphoria followed by •Insomnia
relaxation •Increased appetite
 Impaired memory •Hyperactivity
 Poor concentration •Sensory exaggeration
 Loss of coordination •Mood exaggerations
 Vivid enhancement of •The smell
most senses
 Sedative Drugs
Substance Other Names Forms Methods Harmful Effects
of Abuse
Tranquilizers Valium, Rohipnol, Pills or capsules Swallowed Anxiety; reduced coordination
Lexotan, Dumolid, & attention span. Withdrawal
Xanax can cause tremors and lead to
death
Barbiturate Downers, barbs, Pills or capsules Swallowed Causes mood changes and
yellow jackets, reds excessive sleep. Can lead to
coma.
Hypnotic Quaaludes, ludes, Pills or capsules Swallowed Impaired coordination &
sopor judgment. High doses may
cause internal bleeding, coma,
or death
 Management of Drugs Overdose
 Immediate measures of patient status for in every
case of intoxication regardless of cause, with :
1. Support Vital Functions
2. Identify drug poisoning
3. Reduce the amount of drug in the body
 Principle of the Treatment :
 Treat the patient, not the poison", promptly
 Supportive therapy essential
 Maintain respiration and circulation – primary
 Judge progress of intoxication by: Measuring and charting
vital signs and reflexes
 PRINCIPLE OF THE TREATMENT
• 1st Goal - keep concentration of poison as
low as possible by preventing absorption and
increasing elimination

• 2nd Goal - counteract toxicological effects at

effector site, if possible

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 Support vital life functions (ABC’s)
• Airway – endotracheal tube if needed, watch for fluid accumulation in airway (i.e..
Aspiration of vomit)

• Breathing – Supplemental Oxygen, bag valve mask (BVM) and respirator.

• Circulation – Monitor ECG, watch for arrhythmias, cardiac arrest and shock

– Vasogenic Shock – faulty vasomotor tone, increase capillary permeability.

– Cardiogenic Shock – inadequate cardiac output can be due to cardiac dilation

(barbituate, Ca channel blocker)

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General Treatment of a Comatose Patient
o There are several general antidotes that are used in
the treatment of comatose patients upon
presentation at the hospital.
o Treat all patients who come into the hospital in a
coma with glucose, insulin and naloxone.
o Use drugs to treat emergent conditions, ie:
 Seizures – anticonvulsants (diazepam)
 Cardiac Dysrhythmias – anti-arrhythmias
(lidocaine/amiodaron, DC cardioversion)
 Severe Agitation – anxiolytics (benzodiazepine)

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 Identification the poison
• Patient history

• Laboratory testing

• Comparison of drugs or chemicals with known

toxicology standards.

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 Identification of the Poison
(Sample Types)
• Urine - 1st choice – easier to detect presence of the
drug due to the accumulation of drug in the urine.

• Blood/Serum – 2nd choice – get exact serum levels to

better identify the effects of the drug

• Gastric Contents – 3rd choice –less helpful, but can tell

if you should perform a gastric lavage.

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 Identify Poison (Tests)
• Urine tests
• Immunoassay (EMIT, ELISA) – semiquantitative tests usually with
automated instrumentation. Can detect cannabinoids,
amphetamines, cocaine, barbs etc.
• Thin Layer Chromatography (TLC) – ToxiLab, 4 stage solvents,
qualitative test

• Urine/Blood tests
• High Performance Liquid Chromatography (HPLC), gas
chromatography and Gas Chromatography/Mass Spectroscopy
(GCMS) are quantitative tests that can detect many compounds.

Can be done in 2 hours

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 Removal of the Drug (Emesis)
• Utilize syrup of Ipecac to Induce
emesis to remove unabsorbed drug.
• Emesis inducers
– Mechanical by stroking posterior
pharynx
– Apomorphine parenteral
– Syrup of ipecac 30 ml (1 oz) followed by
one glass of water (150-200 ml)
– Contraindications?

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 Contraindications of Emesis

• Emesis is contraindicated in cases of:

• Petroleum hydrocarbon solvent – chemical pneumonitis
• Caustic acid or alkali agent (rupture)
• Seizing Patient
• Comatose Patient

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 Removal of the Drug
(Gastric Lavage)
• Gastric Lavage – washing of the
stomach. (early tx.)

• A tube is inserted through the

nose or mouth, down the
esophagus, and into the stomach.
Sometimes a topical anesthetic
may be applied to minimize
irritation and gagging as the tube
is being placed.

• Stomach contents can be removed

using suction immediately or after
irrigating w/ fluids through the
tube.

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 Activated Charcoal/Cathartics
• Activated Charcoal (AC)
• Used to bind compounds and to prevent absorption in the GI
tracts. (many drugs)
• Contraindicated with caustic agents and petroleum distillates
due to the lack of absorption of these agents by the charcoal
and risk of vomiting associated with the charcoal
• use of charcoal & ipecac concurrently not recommended

• Cathartics
• Promotes rapid passage of poison through the GI tract
• Counteracts the constipative effects of AC
• I.E. sorbitol, Mg Citrate, Mg Sulfate

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 Removal of the Drug (Other)
• Alteration of pH of urine – to enhance excretion of the drug, useful for
salicylates, chlorpropamide, etc
• Diuresis – often used in conjunction with urine pH alteration
• Dilution with water – useful in the treatment of skin or eye exposure to
harmful agents. ( no neutralizers)
• Demulcents – soothes mucous membranes and coats the stomach, i.e.
milk of magnesia
• Purgation
• Used for ingestion of enteric coated tablets when time after ingestion is
longer than one hour
• Use saline cathartics such as sodium or magnesium sulfate
• Hemodialysis – blood transverses a semipermeable membrane that is
bathed in dialysis solution or dialysate. Drugs or toxins diffuse across
this membrane. (protein binding)

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 B. Antidotal Treatments
A. Heavy Metals
Chelators (BAL, EDTA) complexes with the metals
making them inert
B. Heparin
Protamine (base) binds to acidic heparin to terminate
its action and is excreted by glomerular filtration.
C. Toxins-
Botulinum Toxin
Most potent poison known, rapidly absorbed and
prevents ACH release from nerve terminals
Tx: ABCs, lavage, emesis, charcoal,Trivalent anti-toxin
Mortality of 70% to 10% with treatment

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• D. Organophosphates
• Pralidoxime is a nucleophillic reagent that ties up the
organophosphates and permits its excretion.

• E. Cyanide
• Binds to cytochrome oxidase, LD50= 2mg/kg
• Causes death in 1 to 15 minutes at high doses.
• Chelator is made in the body, methemoglobin (Fe3+)
• Give Amyl Nitrites and Na Nitrite with O2 and whole
blood to convert hemoglobin to methemoglobin (LD50
increases 5 fold) .

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