1 OBJECTIVES

• Provide an overview of fentanyl effects • Compare fentanyl to other common opioids • Identify risks associated with street fentanyl • Introduce members of the "fentanyl family" • Describe features of overdose with fentanyl • Briefly outline how an overdose would be treated What is Fentanyl?

• Fentanyl is an opioid pain killer in the same class as codeine, morphine, and oxycodone • It can be used safely when prescribed by a health professional and taken as directed • Fentanyl is also produced and sold illegally Therapeutic Uses of Fentanyl

• Fentanyl is an important medication for people with severe pain (surgical, cancer-related, end of life) • Access to prescription forms of fentanyl is well controlled but diversion can still occur • Fentanyl is a very potent drug – up to 100X stronger than morphine and 50x stronger than heroin • There are members of the "fentanyl family" in current medical and / or veterinary use that are much stronger than fentanyl Other Types of Fentanyl

• Sufentanil - used in palliative care up to 10X stronger than fentanyl • Carfentanil - is up to 100x stronger than fentanyl

Because of its strong opioid effects, fentanyl has a potential to be abused Illegal use of street fentanyl

• There is a market for fentanyl as a drug of abuse • Fentanyl patches may be diverted from medical sources and cut up for sale as "chicklets" • There is an ongoing trend towards a powdered form that is illegally imported from international sources (mostly China) • Because of the extremely high strength of pure fentanyl powder, it is very difficult to dilute appropriately. This leads to a mixture that may be too strong and very dangerous Illegal forms of Street Fentanyl

• Can be taken orally, smoked, snorted, or injected • Sold as : pills, patches, blotters, powder, forms that resemble popcorn or nerds candy • All have the potential to be lethal Mixing with other street drugs

• Fentanyl is often added to other drugs without the users knowledge • Traces have been found in cocaine, Xanax, methamphetamine and marijuana • Fentanyl is sometimes sold as heroin, often leading to overdoses • Organized crime groups press the powder form into fake OxyContin tablets (greenies)

Real  Fake Mixing Fentanyl with other ingredients You can not guarantee how much of the drug you are receiving . Is Fentanyl Addictive?

• If you use fentanyl as prescribed by your medical professional, you are less likely to become addicted to fentanyl. But like any opioid it could happen. • If you use fentanyl to get high, there is a greater risk of becoming addicted The new kid on the block: Carfentanyl

• Carfentanyl is about 100x more toxic than fentanyl • Carfentanyl was never intended for use in humans • It's most common use is to tranquilize very large animals in veterinary practice • Known as the "elephant tranquilizer" • As little as 10mg of carfentanyl would be needed to sedate or even kill an elephant Carfentanyl

• A deadly dose of carfentanyl may be as small as 20 micrograms (0.02mg)

• A single snowflake weighs about 30 micrograms!! How dangerous is the Fentanyl family? • Fentanyl is a very potent drug – a very tiny amount equal to 2 grains of salt can be lethal • The effects of fentanyl occur very quickly • Intoxication and overdose can occur before the user is even aware something is wrong • The difference between an effective dose and a lethal dose is very small • Fentanyl is not a very forgiving drug in overdose situations

A deadly dose of fentanyl is 2mg which is equal to just 2 grains of salt Cocaine Overdose • Cocaine overdose vary. • Compulsive use involves an overwhelming urge to use more cocaine than is intended can lead to toxicity(poisoning) • Cocaine overdoes can result in permanent damage to the : Brain Heart Muscles Kidneys Over the Counter Medications

•Drug overdoses occur when a person takes more than the medically recommended dose of a prescription or over-the-counter drug.

•Drug overdoses can involve people of any age. It is most common in very young children (from crawling age to about 5 years) and among teenagers to those in their mid-30s.

•An adult (especially elderly persons or people taking many medications) can mistakenly ingest the incorrect medication or take the wrong dose of a medication Over the Counter Medications

Common types of over the counter Medications overdosed on : • Acetaminophen • Aspirin • Barbiturate( sedative ) • Ritalin • Ephedrine Tricyclic antidepressant overdose(TCA) • TCA overdose is poisoning caused by excessive medication of the tricyclic antidepressant. • Symptoms may include elevated body temperature, blurred vision, dilates pupils, sleepiness, confusion, seizures, rapid heart rate , and cardiac arrest. • TCA overdose may occur by accident or purposefully in an attempt to cause death. What CAN an overdose look like? • Problems with vital signs (temperature, pulse rate, respiratory rate, blood pressure) are possible and can be life threatening. Vital sign values can be increased, decreased, or completely absent. • Sleepiness, confusion, and coma are common and can be dangerous if the person breathes vomit into the lungs (aspiration). • Skin can be cool and sweaty, or hot and dry. • Seizures (convulsions) may occur. • Chest pain is possible and can be caused by heart or lung damage. Shortness of breath may occur. Breathing may get rapid, slow, deep, or shallow. • Abdominal pain, nausea, vomiting, and diarrhea are possible. Vomiting blood, or blood in bowel movements, can be life threatening The Bottom line: • It is dangerous – using fentanyl to get high is very dangerous it only takes a small amount to result in an overdose death • addictive – can be highly addictive when used to get high. It is very strong and fast acting • It's poisonous – fentanyl is up to 100x stronger than morphine and 20-50 times stronger than heroin • It's fast acting – intoxication and overdose can occur before a person is aware something is wrong • You might not know it is there – fentanyl can be added to other drugs without their knowledge Airway Management Airway Management

• Use manual maneuvers and positioning to maintain airway patency • Describe the types of airway opening maneuvers for various patients • Describe the indications, contraindications and precautions of performing airway maneuvers • Apply problem solving techniques required with various types of patients What difficulties can we encounter when clearing an airway?

• Unable to open patient’s mouth • Obesity

• Facial/neck trauma • Swollen Tongue/mouth

• Suspected spinal injury • Equipment Malfunction

• Pregnancy How can we open an Airway Modified Jaw Thrust

Modified jaw thrust

• Mainly used when you suspect spinal injury • Can be used anytime to open the airway • This method can be used on all age groups Head Tilt-chin Lift

Head tilt-chin lift

• Can use this when you do not suspect spinal injury

• this method can be used on all age groups Oropharyngeal (OPA) and Nasopharyngeal (NPA) Airways What is an oropharyngeal airway (OPA)?

• An oral airway device that holds the tongue away from the back of the throat • An OPA also allows for suctioning secretions • An OPA is only used in unresponsive patients • An OPA cannot be used on patients with a gag reflex How do we know what size OPA to use?

Measure from the corner of the mouth to the tip of the earlobe or edge of the jaw. How do we properly insert an OPA in an adult?

1. Select the proper size airway.

2. Open the patient’s mouth.

3. Insert the airway with the tip pointing to the roof of the mouth. When the airway touches the roof of the Once the OPA is properly in place, make sure mouth, the patient is not gagging. If so, remove the turn the airway 180 until the airway follows OPA immediately. the natural curve of the tongue. What is an nasopharyngeal airway (NPA)?

Nasopharyngeal airways (NPAs) provide an alternate method for ventilating patients when OPAs cannot be used.

NPAs should be used when: • the patient’s teeth are clenched • the patient has a gag reflex

MFRs should consider using NPAs because: • they are less likely to cause vomiting • they can be used on semi-conscious patients Things to consider when using an NPA

• Choosing an NPA that is too long may • They do not protect the airway cause gastric distention (air in the stomach) • Insertion may cause a nosebleed, which may lead to aspiration or airway obstruction • Inserting an NPA requires lubrication

• NPAs should not be used with head injured • Inserting an NPA is painful, even with patients lubrication How do we know what size NPA to use?

• Length: measure from the nose to the tip of the earlobe

• Diameter: make sure it can easily fit inside the patient’s nostril Steps for insertion of a NPA

Lubricate the NPA with a sterile, water-based Select a nostril that does not have any obstruction lubricant (the right nostril is preferred- WHY????)

Insert the NPA with the bevel toward the septum (the wall between the nostrils). 4. Insert the NPA carefully. If you meet resistance, gently rotate the NPA side-to-side while advancing. If this does not work, remove the NPA and try the other nostril. Oxygen Delivery Guidelines

• If patient has an altered level of consciousness or is in moderate to severe respiratory distress, place a non-rebreather on the patient flowing at 8-10 L/min • For any other presentations, administer oxygen with a nasal cannula (2-4 L/min) • It is better to start slow and low and increase oxygen delivery as needed based on assessment (e.g. if patient develops moderate to severe SOB, oxygen flow can be increased using appropriate delivery device)

START SLOW AND LOW Oxygen Masks and Bag Valve Masks What is a high concentration mask and when do we use it?

• Non-rebreathers have a reservoir bag attached to the mask. The bag inflates with oxygen when attached to an oxygen cylinder.

• Patients inhale approximately 90% oxygen • The one-way valve between the mask and the reservoir bag prevents the patient’s air from mixing with the oxygen in the reservoir.

• The mask also has rubber washers covering the exhalation holes in the mask. This allows air to escape during exhalation and prevents “outside air” from entering the mask.

• Masks do not fit snug on the face, therefore “outside air” enters the mask. As a result, the patient realistically receives 90% oxygen concentration from a non-rebreather mask.

• MFRs may administer oxygen through a non-rebreather mask. What is a bag valve mask (BVM) and when do we use it? • A bag valve mask (BVM) is used to force air into a patient’s lungs.

• BVMs can deliver up to 100% oxygen to patients when attached to an oxygen cylinder and only 21% when not attached.

• We use BVMs when we need to assist patients with their breathing. How do we administer oxygen with a bag valve mask?

1. Open the airway with the head tilt-chin lift or modified jaw thrust. Insert an OPA or NPA.

2. Tightly secure the proper size mask over the mouth and nose.

3. Gently ventilate the patient (when you breath, squeeze the BVM). What is the difference between one and two person BVM use?

• One-person BVM use requires you to hold the mask securely in place, using the “C & E” technique, while ventilating the patient at the same time.

• Two-person BVM use is preferred because you can maintain a better seal with the mask. • Practice on use of BVM and Airway Devises Safety of Responders How to anticipate, recognize, and manage violent patient encounters to minimize danger to yourself and the patient

Providers face a variety of hazards while on the job. About 10 percent of all provider injuries are a result of some form of violence. An unknown percentage of these violent acts involve patients who have abused some form of drug or medication, and present in an altered state. Safety of Responders • The potential for violence when a patient is under the influence of a drug increases the chances of danger to the Responder. • Under extreme circumstances where the rescuer's life is in danger, the patient ceases to be a patient and should be considered an assailant. • Retreat from the scene in these circumstances • Waiting for law enforcement assistance is appropriate. Contact Ambulance Dispatch to advise them that you have retreated. Safety of Responders

. Develop a plan to safely manage a potentially violent patient. keep the scene in control and anticipate sudden changes in the patient's behavior. . Should be covered by another member of team who can quickly assist if the patient's behavior changes during the assessment and management phase. • stay calm and listen. • Allow the patient to vent while sizing up the situation for potential weapons and escape routes.

Always have a escape route for all rescue personnel at all times . • Consider the possibility of sudden violence if the patient is exhibiting one or more of these behaviors:  Sudden erratic movements  Tightening of facial muscles, arms, hands into fists  Darting eye movement  Fixed stare  Shifting balance into an aggressive posture  Raised voice, rapid speech  Rapid breathing Naloxone Kits

• THIS MEDICINE SHOULD NOT BE USED IN PLACE OF EMERGENCY MEDICAL CARE FOR AN OVERDOSE Naloxone

• Naloxone – an opioid "blocker". It temporarily reverses the effects of an opioid overdose , restoring breathing and preventing death. (Not a safety net) • Naloxone does not last as long as most opioids in the system • May cause abrupt withdrawal symptoms • Up to 6x the usual dose of naloxone might be required because the newer drugs are much more toxic and have unpredictable amounts of opioid in each tablet/etc. Naloxone reversing an overdose So what are you going to do • There is little to no change what you are going to do for this patient as you would do for any patient that is unconsciousness or not breathing. • Assess level of consciousness. Is your patient conscious, alert and oriented. • If your patient is unconscious .Assess CABs immediately. • If your patient is does not have a pulse begin CPR and AED protocol. So what are you going to do

• If you are rescue breathing for a patient that is suspected of a overdose use a one valve mask or a BVM . Never do mouth to mouth as some drugs can be inhaled or absorbed by the rescuer. • If you have indicators that this is a drug overdose and patient is in respiratory arrest begin the Naloxone ( Narcan) protocol . If you are thinking a question there is most likely a person in the room thinking the same question . Ask your question.

Credit to : Michael Morton Jason Nauss