Opiate Overdose

minicrocop

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So ran a call this am for an unconscious person that ended up being DOA, in their 20's, last seen one hour prior to being found. Pretty much a straight forward overdose of an opiate, syringe still in the arm. As it was clear the pt. was a priority 4 and other Law Enforcement issues, step back, ME, etc. Pt. was discovered by a grandparent.

Fast forward a few hours and get called back, Grandparent is now unconscious, in the same location the.deceased had been. Pretty much a carbon copy but alive. I do not know the status of the Law Enforcement investigation and what searches were done of the house. This is a rural town and State Police is the lead Agency.

Going to assume both used the same batch of Heroin.

So pt. presents as an unresponsive female with a RR of 6. I should add that while I am an ALS Level Provider my role here was in a QRS capacity with no ALS equipment / meds. Three findings I did not expect with this pt. Her HR was Tachy 120-140, felt regular but no way to know at that time. Was not a-fib. Pt.'s pressure was 120's / 70's and Spo2 with BVM around 98%. She had a significant amount of bilateral JVD. Lung sounds were present and equal in all fields. I have never heard in person, muffled heart tones but everything sounded normal but again fast rate.

Otherwise no other significant findings. ALS on scene, 2mg of Narcan IN, some improvement, gave another 2mg IV ( dead zone radio and cell so no MC ) Looked like Sinus Tach but I stayed out of the Paramedics way, their show, you know.

No toxicology info and doubt I will ever be told.

So looking for thoughts about the HR, JVD, and B/P. Maybe I do not see enough opiate overdoses but can't recall two from the same location, hours apart, or any presentation with the HR and JVD and B/P as above.

Thoughts.
 
1. Hypoxia causes tachycardia

2. If they were thin, JVD would be present normally. If not tachycardia can cause JVD due to decreased ventricular filling time.

3. If the heroin was cut with fentanyl or one of it's synthetic analogues you won't see a lot of hemodynamic effect, you get little to no histamine release.
 
There are some drugs that are used when weening patients from some substances, similar to suboxone. They are synthetic opiates that usalsfyre was talking about. Some have been known to require 2 to 3 times the normal dose of narcan to resuscitate the patient. Look up buprenorphine.
 
How did you sit the unconscious patient at 45* to properly assess JVD? If they were supine, some JVD is expected.
 
Sounds like another overdose at the same location with the vitals you've provided.
If it looks like a duck, swims like a duck, and quacks like a duck, then it probably is a duck.
 
There's an opioid (forgot name) that causes non-traditional effects, such at dialiated pupils vs pinpoint. Anyone know the name of this drug?
 
I think it's called a speedball...
 
And a speedball isn't only opiates.


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How did you sit the unconscious patient at 45* to properly assess JVD? If they were supine, some JVD is expected.

Initially I noticed the JVD while she was supine and being ventilated...was that, man look at those veins, having never actually started an EJ, this is the one for it is huge.

After the first dose of Narcan, we were able to elevate her but not up to 45* I can honestly say I did not elevate or consider semi 45* to evaluate the JVD, mind was on her maybe vomiting. Nevertheless lets say we are at 25* and second dose of Narcan going on board. The JVD did not change and that was when I reinforced my observation to the Paramedic. He acknowledged but was not overly concerned, it was his show and I am not going to step on feet. My earlier assessment, lung sounds, B/P...didn't support a theory of a TPTX.

What happened down the road with the patient is unconfirmed, guess I will find out if there is a trial. The scuttlebutt is she expired from her underlining COPD, I am sure the opiate played a role. This should come as no surprise that the Mother of the deceased, Daughter of Grandmother, uses IV opiates and while she did not do anything to warrant another visit by EMS to the house, she was taken into custody of the State and no idea where she is now.

Another family member, who stated he knew very little about the activities at the house despite his name being on the lease, is who got the Mom taken into custody. After that the house was vacated and that family is no longer in the area.

Thanks to all who took time to comment.
 
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