Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions

In ACLS (Advanced Cardiac Life Support) one thing is consistent. Poisons are treated the same way before the patient codes, during the code, and after the code. Why?

Dr. James R. Roberts writes that there is no good reason for this –

Don’t confuse post- or pre–arrest toxicologic interventions with the actual cardiac arrest event.[1]

Toxicology is much more complicated than the ACLS guidelines.


American Association of Poison Control Centers

But everybody knows that any potential poisoning/overdose gets naloxone and the megacode is over with a successful resuscitation.

Any medical professional who suggests that naloxone (Narcan) is a resuscitation drug needs remediation or termination.

This is completely wrong and very dangerous thinking. This is magical thinking, which has no place in medicine. This is the kind of thinking that results in everyone being strapped to a backboard based on Mechanism Of Injury.

Don’t think, just do something dangerous.


Image credits – 123

Repeat the mindless sequence as often as necessary, until the desire to understand patient care has been destroyed.

With a dog, the bell ringing only leads to drooling, but medics are generally more dangerous than drooling doggies. Rabies is one way of producing drooling doggies that can compete with medics for ability to cause harm.

What do we expect to get, when we reward ignorance?

Routine naloxone use is a demonstration of incompetence.[2]

naloxone will not reverse cardiac arrest from an opioid.[1]

Only CPR and defibrillation seem to be life-saving. Not unexpectedly, this theme continues with the proclamation that there is no drug, antidote, or intervention that alters the outcome of cardiac arrest from a toxin.[1]

But what about Bicarb?

The use of sodium bicarbonate is not as common as the use of naloxone, but it is no better understood and sodium bicarbonate is a more dangerous drug. As with naloxone, ventilation is more important than medication. That is assuming that acidosis is the problem, which is usually not the case when sodium bicarbonate is given.

Hyperkalemia? Calcium is the treatment, not sodium bicarbonate. We avoid calcium, because we are told that calcium is dangerous and sodium bicarbonate is safe. This is nonsense.[3]

Although a few antidotes have the potential to rapidly neutralize or reverse the toxic effects of drugs in the still living, the majority of one’s arsenal to treat cardiorespiratory collapse secondary to a drug overdose is primarily basic support.[1]

Supportive care is the best treatment for opioid and benzodiazapine overdose when the patient is alive. That is even more true when the patient is dead. Too often we ignore supportive care in favor of magic.

Ignoring respiratory depression/arrest in order to give naloxone or flumazenil (Romazicon) is incompetence.

even flumazenil has “no role in the management of cardiac arrest” from benzodiazepines.[1]

Death from an overdose is quite unusual, probably less than two percent. Those patients who do succumb to their ingestion usually die in the prehospital phase or likely have their fatal course well ensconced before seeing the paramedic or clinician.[1]

If they are still alive when they meet us, we probably will not kill them – unless we do something thoughtlessly routine stupid.

The AHA recognizes that gastrointestinal decontamination, once a generic mainstay in managing any toxin, has a minimal role in changing the outcome of a toxic ingestion.[1]

We can make it difficult/impossible to manage the airway by routinely giving charcoal or ipecac. As I wrote yesterday, ipecac is a really bad idea.[4]

Resuscitation from poisonings with beta blockers, calcium channel blockers, digoxin, tricyclic antidepressants, cocaine, local anesthetics, carbon monoxide, cyanide and more are discussed in the article.

Go read the whole thing and learn a lot about the toxicologic management of resuscitation.

Footnotes:

[1] Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions
Emergency Medicine News:
October 2011 – Volume 33 – Issue 10 – pp 16-18
doi: 10.1097/01.EEM.0000406945.05619.ca
InFocus
Roberts, James R. MD
Article

[2] Naloxone
Rogue Medic
The problems with naloxone in four parts –

Narcan Solves Riddle – Part I
Narcan Solves Riddle – Part II
Narcan Solves Riddle – Part III
Narcan Solves Riddle – Part IV

[3] EMS 12 Lead Bradycardia Post – Part II
Rogue Medic
Article

[4] Ipecac for Tricyclic Antidepressant Overdose
Rogue Medic
Article

.

Comments

  1. A live human study Canadian Journal Public Health 2013;104(3)e200-6. Teaching the general public chest compressions only for poisoning (opiate OD). They have killed a few already 14 yr. old juvenile onset diabetes, 70 yr. old unconscious choking victim plus poisoning (drug OD) deaths. The study continues. No medical authority says a thing. They are making themselves and everyone else sick teaching this nonsense. tfhfeedback@toronto.ca or 416-392-0520

  2. A live human study Canadian Journal Public Health 2013;104(3):e200-4. Teaching the general public chest compressions only for poisoning (opiate OD). They have killed a few already 14 yr. old juvenile onset diabetes, 70 yr. old unconscious choking victim plus poisoning (drug OD) deaths. The study continues. No medical authority says a thing. They are making themselves and everyone else sick teaching this nonsense. Please stop needless suffering tphfeedback@toronto.ca or 416-392-0520

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