Responding to crisis situations part one: respiratory depression and overdose.

Person lying in the recovery position on their side

This series will be looking at how we respond to drug related medical emergencies (crisis situations). CW for discussions of overdose.

Sometimes things go wrong when we take drugs. We don’t have full power over preventing anything going wrong, but we do have power over how we respond.

In Aotearoa, and globally, opioids and alcohol are the biggest contributors to overdose. Benzodiazepines (benzos) and synthetic cannabinoids also cause many overdoses in Aotearoa. This blogpost is aimed at responding to overdoses caused by these drugs. Overdoses are usually accidental, reversible, and treatable. When they are responded to quickly, many make a full recovery.

Having some skills on hand to respond to overdoses could make all the difference between a full recovery, and no recovery at all.

Signs and symptoms

Different drugs cause different overdose symptoms. Most commonly, overdose deaths happen when someone’s breathing slows and then stops, or when they choke on their own vomit.

Such overdose symptoms are usually caused by “respiratory depressants” – drugs that slow your breathing, like opioids, alcohol, and benzos, especially when they are mixed together. The symptoms of such overdoses are listed below.

If someone is overdosing, act right away. When people survive an overdose, it’s because someone was with them and they responded quickly. That someone could be you.

The first step to responding to an overdose is knowing how to recognise one.

The signs of an overdose are:

  • Breathing has stopped, is very slow and shallow, or erratic and strained.
  • Choking sounds or a snore-like gurgling noise (sometimes referred to as death rattle).
  • Unresponsive to loud noises or being shaken.
  • Body is limp.
  • Loss of consciousness.
  • Awake but not responding.
  • Pale or clammy face.
  • Pulse/heartbeat can be irregular, rapid, faint, slow, or not there at all.
  • Vomiting.
  • Chest pains.

When opioids are involved in an overdose, the life-saving medications Naloxone and Nyxoid can be used to reverse it. When opioids are involved in an overdose, many or all of the above signs may be present, as well as:

  • Skin tone, especially around fingers and lips, is either bluish purple for light skinned people, or grayish/ashen for darker skinned people.
  • They are cold to the touch.
  • Pinpoint pupils.

The symptoms of an overdose on synthetic cannabinoids (synnies) are:

  • Foaming at the mouth.
  • High fever.
  • Chest pains.
  • Difficulty breathing.
  • Temporary paralysis.
  • Psychosis.
  • Seizure.
  • Stroke.
  • Sudden loss of consciousness (dropping).
  • Unpleasant hallucinations.

For more information on being safer with synnies, check out the resource on the Level’s website

Responding to an overdose

Step 1: Assess for dangers.

Check the immediate environment for any hazards such as uncapped needles or oncoming traffic.

Step 2.1: Attempt to get a response.

Yell out simple questions – “can you hear me”, and “what’s your name”. Approach with caution if you don’t get a response. Try squeezing their shoulders, or making a fist with your hand and using it to rub firmly up and down on the centre of their chest (called a sternum rub). Them moving or making noises counts as a response.

Step 2.2: Call 111 or get someone else to.

Tell the ambulance staff there is an overdose, someone is not responding or breathing, and what drugs you think caused it.

Step 3: Lay the person down.

Lay them flat on their back on the floor.

Step 4: Check their airways.

Tilt their head back, lift their chin, and look inside their mouth. If there’s anything in the way of their throat, tilt their head to the side and use two fingers to scoop it out.

Step 5: Check breathing.

Look and feel to see if their lower chest and upper abdomen is rising and falling. Listen and feel for air coming in and out of their mouth. Ignore occasional gasps or very strained breathing inadequate to sustain life.

Step 6: Administer Naloxone/Nyxoid (if opioids are involved in the overdose)

Injectable

Draw up entire vial using a syringe and inject either into outer thigh muscle, or upper arm below the shoulder.

Injection site in the upper arm
Injection site 1: Deltoid muscle in the top bit of the upper arm just below the shoulder. Image source: Geeky medics
Injection site for the outside of the thigh
Injection site: Outer thigh muscle, just below the juicy bit (and yes that is the technical term). Image source: Geeky medics

Nasal

Check that nasal passages are clear, and if they aren’t, clear them. Stick the device all the way up one nostril and click the plunger. Make sure the device is inserted fully.

If the person doesn’t respond and isn’t breathing well within 2-3 minutes, administer a second dose.

With Nyxoid, administer the dose in the opposite nostril. Perform CPR in between doses.

Step 7: Perform CPR.

This step isn’t necessary if the person is already breathing well.

Step 8: Recovery position.

When they’re breathing well on their own, lay them in the recovery position.

Person lying in the recovery position on their side
Put your human in recovery position to ensure a clear airway for adequate breathing and to prevent inhalation of vomit. Image source: Health Navigator

For more information:

Download the NZ Needle Exchange and NZ Drug Foundation’s guide to giving someone Nyxoid spray and other tips on avoiding opioid overdose (PDF, 352.9KB)

Check out the guide on using injectable Naloxone on the Level website

CPR

If the person is still not breathing well, perform CPR by following these steps:

Start with compressions. Compressions are the most important part of CPR.

  • Place the heel of one hand in the centre of their chest.
  • Place the heel of your other hand directly on top of your first hand.
  • Keep your elbows locked, and lean over them so your arms are straight.
  • Push down hard and fast 30 times (pushing down about 1/3rd of their chest depth). Don’t worry about pushing too hard, good CPR requires hard and fast pushing.
  • After 30 pushes, breathe into their mouth twice.

Next, breathe into the person

If you do not wish to perform this step due to the risk of transmitting or receiving viral infections, continue to perform compressions. You can also do this while wearing a facemask. Compression only CPR still saves lives.

  • Tilt their head back with one hand and lift their chin with the other.
  • Take a deep breath in, and seal your lips around their mouth. Use a CPR face shield if you have one to reduce the transmission of viruses. You can get them from the Heart Saver NZ website
  • Block their nose by pinching the soft part of it.
  • Blow into their mouth until you see their chest rise.
  • Remove your mouth, take a fresh deep breath in, and repeat once.

Start again with the compressions.

Recovery position.

When they’re breathing well on their own, roll them into the recovery position.

Seizures

Seizures/convulsions can be triggered by certain drugs and drug combinations, and are sometimes a symptom of life threatening overdose. There are many different types of seizure, some mild and short-lived, some severe and prolonged. Always call an ambulance if someone has a seizure after taking drugs.

Signs and symptoms

  • Jerking/twitching of face and limbs.
  • Foaming at the mouth.
  • Loss of consciousness.
  • Loss of bladder/bowel control.
  • Blue/purple skin and lip colour.

If someone is having a seizure, follow these steps:

Step 1: Protect them from injury.

  • Clear the person’s immediate physical environment of anything they could smack into during the seizure, including furniture and appliances.
  • Take special care when moving anything electrical or anything hot that could cause burns.
  • If they’re near a wall, pad the wall with pillows or clothing.
  • Don’t try to restrain them. Restraining someone having a seizure can result in physical injury to both parties.
  • Don’t attempt to pad between their teeth. Doing this can also result in physical injury to both parties, or choking.

Step 2: Manage the convulsions.

  • Stay with them until the seizure ends.
  • Keep others from interfering with the person having the seizure, and assure them the seizure will end soon.
  • Time the seizure and keep note of how long it takes

Step 3: Recovery

  • When the seizure ends, roll them into the recovery position and open and clear their airways. Gently cover them with a coat or blanket.
  • Monitor their breathing
  • Allow them to sleep until fully recovered or medical staff arrive.
  • Don’t let them eat until they have been assessed by medical staff, as they could have another seizure and choke on the food they’re eating.

Talking to medical staff

Calling medical staff in an emergency involving drugs can be scary. Remember though, they’re not there to punish or judge anyone. Their job is to respond to harm. The only times medical staff are allowed to bring police along to a medical emergency is if they suspect someone is behaving violently or threateningly.

Tell the medical staff as much info as possible, such as

  • the drugs involved,
  • the time and duration of overdose symptoms,
    and
  • any known medical history.

The more informed medical staff are, the better equipped they are to respond, and the more likely your friend is to survive.

Aftercare

People can behave unpredictably when waking up from a medical emergency involving drugs, and the experience may be traumatic to them. As they’re waking up, give them a bit of space and be as gentle and embracing as you can.

The person may be overwhelmed, agitated, scared, and/or disoriented. Keep communication short and to the point – “hi friend, it’s (name). You were just unconscious. I’m here for you and you’re safe”. Repeat yourself until they’re fully alert. Try to stay with them for at least 90 minutes, but if they’re set on leaving, don’t stop them. Follow them from a safe distance if they seem to still be in danger.

A medical emergency is no time for shouting, arguing, blaming, or shaming. They’re already scary situations, so everyone involved benefits from a gentle approach. In crisis situations, we’re forced to make snap judgements without having time to think or process. This can make people feel powerless, fearful, angry, distraught, or disconnected. None of these feelings are wrong, they’re natural responses to scary life or death situations.

As important as it is to be gentle with the person who’s had the medical emergency, it’s also important we be gentle with ourselves. When we feel powerless it’s normal to feel angry, and it can be hard to behave in ways that are in line with our values when we’re scared, too.

We aren’t defined by our feelings, or the ways we behave when we’re scared. We can always own up to our mistakes, learn and change so we do better next time, and hopefully prevent a next time altogether.

It may feel important to seek support and care after being in a crisis situation. We encourage you to seek this out in your community, peer support services, and with your GP or a therapist. If you find yourself often responding to crisis situations, give yourself permission to take some time out. A resilient community relies on many individuals working together so everyone can access care, support, and rest.

Thanks to the folks at the National Harm Reduction Coalition for their resources that inspired much of the content here. Download the infographic on welcoming people back from opioid overdoses from their site.

Harm reduction

Because illegal drugs are unregulated, accidental overdose is always a possibility no matter what drugs are being taken. Drug supplies can be poisoned with highly potent synthetic opioids, or sold as something they’re not.

A great way to prevent accidental overdoses and medical emergencies, is to get your drugs checked by KnowYourStuffNZ, or any other organisation that provides drug checking.

You can also follow High Alert, which puts out alerts when drug supplies are found to be contaminated, sold as something they’re not, or super high risk.

Injectable Naloxone and nasal spray Nyxoid are life saving, opioid overdose reversing medications.

Nyxoid comes in packs of two, each containing one dose. Two doses of Nyxoid are enough for responding to most opioid overdoses in Aotearoa, but more doses may be necessary for responding to overdoses caused by very potent synthetic opioids.

Nyxoid can be found at some pharmacies for $92, and can be ordered into many pharmacies ahead of time. Naloxone is available on prescription for people currently in an opioid substitution programme, but sometimes can be prescribed in other cases, too, so check with your GP.

Both Nyxoid and Naloxone are available at some Needle Exchange outlets. Sourcing the medications this way is a good option for anyone struggling to source them through the high cost of pharmacy Nyxoid or through GP prescription of Naloxone..

For more information including which Needle Exchange outlets supply Naloxone/Nyxoid, read our blogpost on fentanyl, Nyxoid, and Naloxone

Farewell

Thanks for taking the time to inform yourself on responding to medical emergencies. See you next time in part 2, where we will be covering cardiac arrest, fainting, heatstroke, and other medical emergencies.

Published by Naomi

Naomi is a student and peer support worker/advocate who specialises in the intersections of drug harm reduction, transness, neurodiversity, and addressing the societal determinants of health.

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