Protocol question on suicides where they OD on sleeping pills..

flightnurse2b, LPN · Oct 7, 2008

it depends on the patient stability, underlying medical problems, etc and what med they took and how much of it they took .. there really is not a blanket answer for an OD because they are all a little different.

for some patients, you may just let them sleep and monitor them, esp if they have a high tolerance for meds. others may need gastric lavage with activated charcoal, usually when etoh is involved... we NEVER used ipecac. some meds such as apap, benzos and opioids have antidotes for reversal. some people have drug idiosyncracy (sp) and require sedation and restraints on occasion.

hope that helps a little.

Jolie, BSN · Oct 7, 2008

Disclaimer: I'm a NICU nurse who hasn't touched an adult for nearly 15 years, so I may be way off base. (If I am, I hope you'll tell me so :)).

But it seems to me that once you have administered an antidote and/or given activated charcoal, there isn't much you can do to keep a patient awake. The drugs that remain in the patient's system will have their effect, and if that effect is to cause sleep, you probably can't do much about it. Even if you could, keeping the patient awake won't prevent the drugs from exerting their harmful effects.

So I assume you would do regular neuro checks, assess the patient's level of consciousness and perhaps assess a GCS, but I don't know how you could possibly prevent a patient from sleeping.

Noryn · Oct 7, 2008

This reminds me of a situation that occurred in my hospital. A patient's heart rate went to 30 while they were sleeping. The solution according to the nurses in charge? Wake the pt up and walk him around the room. Almost the same idea here. Hollywood has dramatized keeping people awake. Does this really work? Not really.

I agree with letting them sleep. You will still arouse them q 15-30 min as appropriate to determine their loc. It really depends on what medications they overdosed on as opposed to what treatment you will provide. I still cannot figure out why you give charcoal to a lethargic pt. (in general with no protected airway). Nothing like ensuring a cns depressed pt's stomach is full!

Many of your sleep medications, especially over the counter are going to be antihistamines. In low amounts they may make you drowsy but in large amounts they make you anticholinergic. Wild, agitated, combative, etc. If this occurs you will be giving them medication to make them sleep.

So no, there really is no point in keeping them awake. If anything you may promote agitation. I would hope your instructors have told you that ipecac is almost never recommended (as close to saying never as can be). Ipecac causes prolonged vomiting. Not good in a cns depressed pt.

justme1972 · Oct 7, 2008

This reminds me of a situation that occurred in my hospital. A patient's heart rate went to 30 while they were sleeping. The solution according to the nurses in charge? Wake the pt up and walk him around the room. Almost the same idea here. Hollywood has dramatized keeping people awake. Does this really work? Not really.
I agree with letting them sleep. You will still arouse them q 15-30 min as appropriate to determine their loc. It really depends on what medications they overdosed on as opposed to what treatment you will provide. I still cannot figure out why you give charcoal to a lethargic pt. (in general with no protected airway). Nothing like ensuring a cns depressed pt's stomach is full!
Many of your sleep medications, especially over the counter are going to be antihistamines. In low amounts they may make you drowsy but in large amounts they make you anticholinergic. Wild, agitated, combative, etc. If this occurs you will be giving them medication to make them sleep.
So no, there really is no point in keeping them awake. If anything you may promote agitation. I would hope your instructors have told you that ipecac is almost never recommended (as close to saying never as can be). Ipecac causes prolonged vomiting. Not good in a cns depressed pt.

Thanks everyone! Now I understand better.

Noryn, they did tell us that we should never administer ipecac without a physician's order, direction from poison control, or when the swallowed substance is unknown, or to any patient who can potentially have altered LOC b/c of aspiration risk and not to mix it with activated charcoal.

I have never seen it used, so I didn't know that it cause prolonged vomiting. Thanks for the tip!

You are correct that part of my hesitation was what I have seen on television where heroic efforts were made to keep a patient awake if they OD'd on sleeping pills.

Our textbook doesn't give the rationale for these odd types of questions, so I had no clue as to what the rationale would be.

Thanks!

Roy Fokker, BSN, RN · Oct 7, 2008

It depends on their presenting status.

All my OD patients get hooked onto a monitor. I'm not all too hung up on them wanting to sleep - if their hemodynamic status is stable enough to permit it, sure go ahead and take a nap.

If I'm that concerned about their drowsiness/status, I'll usually talk with the Doc and more often than not we end up tubing them.

There is no 'one size fits all' - It's all about risk Vs benefit. If I think that their basic Cardiovascular or Neurological status is under significant risk, I'm not opposed to aggressive treatment.

cheers,

NewWayofLife · Oct 7, 2008

This is a bit nit-picky, and I apologize for that, but as a survivor of several family suicides, I'd call it a pet-peeve of mine.

I believe you meant to say "suicide attempt" and not "suicides" as a "suicide" is meant to refer to a successful attempt.

My intention is to educate, not to belittle. I hope you take it that way.

ERNurse752, RN · Oct 8, 2008

Ipecac and gastric lavage are not typically recommended anymore, although there are a few cases where they can be used.

Activated charcoal can be given to a patient if it is less than 1-2 hours post ingestion, and they are awake and alert. There are a few cases where charcoal can have benefits given more than one time, or given later in the ingestion - like aspirin. It should not be given to a patient who is already sleepy, because their risk for aspiration is increased. Risk for aspiration is also greatly increased when charcoal is given via NG or OG, so that is also typically not recommended.

Sleeping is fine. Any patient who is sleepy from whatever they overdosed on should be on a cardiac monitor and pulse oximetry. A 12 lead EKG should also be done. Treatment depends on what kind of "sleeping pill"' they took, as that can cover more than one class of drug. But bottom line, you monitor their airway and respiratory status. If there is a lot of concern, they should be intubated to protect their airway.

Poison Control should always be called. Even if it something you're familiar with, poison centers collect data for research and epidemiological purposes besides just giving tox advice.

Trauma Columnist · Oct 8, 2008

Much depends on the med also: ambien and sonata and lunesta - you give activated charcoal to attempt to neutralize. However, with elavil, a tricyclic used often for insomnia, you need to carefully monitor the patient as they become acidotic and quit breathing and charcoal isn't too helpful. For benzos, like ativan, you again want to closely monitor them for resp depression.

There should be a standard protocol for attempted suicides and/or overdoses - few of these patients tell you the truth and as ER personnel, our job is to keep them safe - I would always monitor these pts closely and provide one to one supervision if necessary.

ERNurse752, RN · Oct 8, 2008

Ditto Elavil and other tricyclics - very bad in overdose. Rapid CNS/resp depression, tachycardia, wide QRS, v tach, seizures, etc. You can let them sleep too, but be prepared to rapidly intubate and to deal with the other potential problems that will very likely occur.