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• 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

OBJECTIVES

• 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

What is 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

Therapeutic Uses 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

Other Types of 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 use of street fentanyl

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

• 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)

Mixing with other street drugs

FakeReal

Mixing Fentanyl with other ingredients You can not guarantee how much of the drug you are receiving .

• 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

Is Fentanyl Addictive?

• 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

The new kid on the block:Carfentanyl

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

• A single snowflake weighs about 30 micrograms!!

Carfentanyl

• 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

How dangerous is the Fentanyl family?

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 HeartMuscles Kidneys

•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

Over the Counter Medications

Common types of over the counter Medications overdosed on :

• Acetaminophen

• Aspirin

• Barbiturate( sedative )

• Ritalin

• Ephedrine

• 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.

Tricyclic antidepressant overdose(TCA)

• 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

What CAN an overdose look like?

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

• 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

Airway Management

• Unable to open patient’s mouth

• Facial/neck trauma

• Suspected spinal injury

• Pregnancy

What difficulties can we encounter when clearing an airway?

• Obesity

• Swollen Tongue/mouth

• Equipment Malfunction

How can we open an Airway

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

Modified Jaw Thrust

Head tilt-chin lift

• Can use this when you do not suspect spinal

injury

• this method can be used on all age groups

Head Tilt-chin Lift

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 unresponsivepatients

• 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 mouth,

turn the airway 180 until the airway followsthe natural curve of the tongue.

Once the OPA is properly in place, make sure the patient is not gagging. If so, remove the OPA immediately.

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

What is an nasopharyngeal airway (NPA)?

• Choosing an NPA that is too long may cause gastric distention (air in the stomach)

• Inserting an NPA requires lubrication

• Inserting an NPA is painful, even with lubrication

Things to consider when using an NPA

• They do not protect the airway

• Insertion may cause a nosebleed, which may lead to aspiration or airway obstruction

• NPAs should not be used with head injured patients

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

Lubricate the NPA with a sterile, water-based lubricant

Select a nostril that does not have any obstruction

(the right nostril is preferred- WHY????)

Insert the NPA with the

bevel toward the septum

(the wall between the

nostrils).

Steps for insertion of a NPA

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

• 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

What is a high concentration mask and when do

we use it?

• 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).

• 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.

What is the difference between one and two

person BVM use?

• Practice on use of BVM and Airway Devises

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 .

Safety of Responders

• 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 – 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

Naloxone reversing an overdose

• 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 .

So what are you going to do

Credit to :

Michael Morton

Jason Nauss

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