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
absence 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
 Alcohol (ethanol) abuse
• Acute  high amount of ethanol concentration
• Chronic  small to medium amount ingested routinely
Ethanol metabolism Where alcohol metabolism
take place
 Alcohol-Drugs Interactions
• Fact & reality around alcohol
– Some medications—including painkillers and cough, cold, and allergy
remedies—contain ≥1 ingredient that can react with alcohol.
– Certain medicines contain up to 10 percent alcohol. Cough syrup
and laxatives may have some of the highest alcohol concentrations.
– Alcohol affects women differently  higher alcohol blood level
– Older people face greater risk  slower rate of alcohol metabolism
– Timing is important Alcohol and medicines can interact harmfully
even if they are not taken at the same time.

Alcohol – Drugs Interactions…… How are the

mechanism?
 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 Consider to 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 (benzodiazepin)
 Cardiac Dysrhythmias – anti-arrhythmias (lidocaine, digoxin)
 Severe Agitation – anxiolytics (short acting 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, barbiturates, 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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