We are there for the good of the patient, not for the good of the protocol, not for the good of the medical director, and not for the good of the company.

- Rogue Medic

To Narcan or not Narcan

 

Image credit.
 

EMSDoc911 writes about whether naloxone (Narcan) is a good idea for a specific patient presentation.
 

Dispatched for a 50ish yo witnessed cardiac arrest, CPR in progress on my arrival.

The pt was pulseless in brady..ish PEA with agonal respirations. He received ~2min of CPR by us when we got a pulse back. Intubated, IV, no code meds as we never got around to it. Per bystanders, the pt “started crying, then collapsed into a code… we got there in <5min.

As I started doing my secondary assessment in the truck, I noticed on my neuro exam that the pt has pinpoint pupils. So to Narcan or NOT Narcan???

Note: the pt is 250+ lbs, intubated, with IV, yada yada yada… we are 12min from ED, and it is just me & a firefighter in the back.[1]

 

Should we give this patient naloxone?

We should only be giving drugs when they are indicated.

1. Is there any benefit to the patient?

2. Is there any harm?

3. How much uncertainty is there about what will happen?

There is always uncertainty, but never certainty. We need to understand how uncertain we are.

Certainty would imply that we never make mistakes.

Some people do claim to never make mistakes. These are people who never make any decisions (I would call that a mistake) and liars. If you are in EMS and you tell me that you have never made a mistake, then you are either brand new and do not have enough experience to recognize mistakes or you are a liar.
 

1. What are the possible benefits from giving naloxone to this patient?

We do not have to squeeze the bag.

We can extubate the patient in the field. This is also one of the possible harms, because extubation does not always go as planned – just ask a doctor who extubates a lot of patients.

We have a better idea of what happened.

In other words – not much benefit.
 

2. What are the possible harms from giving naloxone to this patient?

A. If this actually is an opioid overdose –

He has some stimulants on board and becomes combative.

He has some stimulants on board and the catecholamine surge puts him back into cardiac arrest.

If the patient has taken an opioid and that is keeping stimulants, this is about the same as deciding if we should give a bolus of epinephrine to a resuscitated patient.

We may end up fighting with the patient in the back. Not good for the resuscitated patient and not good for us.

B. If this is not an opioid overdose –

Should we be giving drugs to someone on a hunch?

The naloxone with wipe out the protective effect of endorphins – the body’s natural opioids.

Block the effect of endorphins and we cannot safely use opioids. Naloxone is a competitive antagonist, but what is an effective dose of morphine, or fentanyl, after giving naloxone? How do we know?

Can we really titrate naloxone that accurately that we can stop before any adverse effects cause problems?

If we answer Yes – we are lying to ourselves. Sometimes this will work, but other times it will not – and that is just in giving naloxone, not in giving morphine to a patient who has already received naloxone to treat a potential overdose of heroin, or fentanyl, or methadone, or tramadol, or hydromorphone, or any of the other opioids used on the street, whether smoked, or injected, or swalloed, taken as a transdermal patch, or rubbed on the gums, or something else.
 

3. How much uncertainty is there when giving naloxone to this patient?

Has the patient taken something that will respond to naloxone?

Will the patient be able to tolerate the expected catecholamine surge if the naloxone has a clear effect.

The adverse reactions section of the FDA (Food and Drug Administration) label includes the following –
 

pulmonary edema, cardiac arrest or failure, tachycardia, ventricular fibrillation, and ventricular tachycardia. Death, coma, and encephalopathy[2]

 

Those are just the cardiovascular adverse events.

While the risk of these adverse reactions is small, it may be larger in the intubated patient, or in the post-arrest patient. The possible benefits are tiny, while the possible harms are the kind that

The uncertainty is huge.

Is the significant risk justified by the tiny possible benefit?

Go read what EMSDoc911 wrote, but remember that a good outcome does not mean that the decision was the right decision. If that were the case, betting my paycheck on the flip of a coin would be a good decision if I win, but only a bad decision if I lose.

We cannot justify our decisions based only on the knowledge of the outcome, because we don’t know the outcome until after we have taken the risk.

 
Also see – The Myth that Narcan Reverses Cardiac Arrest

Footnotes:

[1] To Narcan or not Narcan
EMSDoc911
Dec 11, 2012
Article

[2] NALOXONE HYDROCHLORIDE injection, solution
[Hospira, Inc.]

DailyMed
FDA Label
Adverse Reactions

.

Comments

  1. LOL, I was just thinking about how you would respond to this article when you posted here.

    With regards to the EMSDoc911 post, my decision would be based around the ET tube. If he’s tubed, there’s no reason for the naloxone: his airway is secured and bagging is providing enough oxygen/ventilation. If his airway was not secured (BVM with OPA), then I probably would have titrated naloxone until his respiratory rate was back to 10 per minute.

    However, your remarks about a catecholamine surge is a good point, and something I had not considered. Thanks for giving me something to think about.

    • Question from one of you about the Narcan:

      “How would he have “recoded from [you] NOT giving the narcan?” Wasn’t he intubated, and didn’t you have control of his airway?”

      Opioid OD not only has profound respiratory depression aspect but also a marked cardiac depressive effects. Therefore by NOT administering narcan, you are NOT reversing his respiratory depression in addition to maintaining depressed cardiac function. Given the fact that he may (or may not) have just came out of a cardiac arrest, the importance of enhancing his cardiac function & reversing the immediate cause of his potential cardiac arrest is paramount. Hence, narcan, which addresses both, the resp AND cardiac depression.

      As I’ve explained earlier, the patient may NOT have been a code (but damn sure looked like it when I first got there), hence the chances of him re-coding are significant b/c of the cardiorespiratory depressive effects of his narcotic OD. I may have truly NOT felt a pulse because he was so hemodynamically collapsed that his blood pressure may have been 50/poop, thus no carotid pulse… and PEA. The two minutes of extremely effect compressions could have gotten his blood pressure up just enough for his heart to catch back up. True I had his airway secured, but that is only one component of this very complicated equation, albeit probably the most important one.

      Narcotic OD codes usually have a 3 part component:
      1) respiratory arrest leading to cardiac arrest,
      2) cardiac arrest precipitated by profound cardiac depression AND/OR
      3) hemodynamic collapse 2/2 histamine release that is accentuated by stimulation of endogenous narcotic receptors within the body.

      Administration of Narcan would counteract the first 2 causes by reversing resp depression, increasing the inotropic activity of heart (yes narcan actual has inotropic properties, I re-looked it up for you :), and releasing catecholamines all contributing to improvement of the patient’s hemodynamics. Narcan however does nothing on the massive histamine release that the opioids already did (analogous to a milder version of anaphylactic shock)… that damage is already done. Hence, the further importance of improving his cardiovascular function.

      So in summary, just because the patient has an “intact airway” says nothing for the rest of him which is still reaming from the effects of his AyRhone. I hope this answered your question.

      ~Reference: “Naloxone in cardiac arrest with suspected opioid overdoses” by Saybolt, MD, et al.

      • EMSDoc911,

        Question from one of you about the Narcan:

        “How would he have “recoded from [you] NOT giving the narcan?” Wasn’t he intubated, and didn’t you have control of his airway?”

        Opioid OD not only has profound respiratory depression aspect but also a marked cardiac depressive effects. Therefore by NOT administering narcan, you are NOT reversing his respiratory depression in addition to maintaining depressed cardiac function. Given the fact that he may (or may not) have just came out of a cardiac arrest, the importance of enhancing his cardiac function & reversing the immediate cause of his potential cardiac arrest is paramount. Hence, narcan, which addresses both, the resp AND cardiac depression.

        I do not see anything about his presentation that suggests that he might benefit from more catecholamines. We use catecholamines to treat impaired perfusion, not adequate perfusion. From what you wrote, I do not see any reason to presume any inadequacy of his perfusion. You were there, so was there something that suggested impaired cardiac output, or impaired perfusion, to you?

        Should we even be using catecholamines?

        Catecholamines Should Be Banned – Mervyn Singer.

        This page has a link for a free mp3 download from Free Emergency Medicine Talks – an excellent site run by Dr. Joe Lex of Temple University Hospital.

        As I’ve explained earlier, the patient may NOT have been a code (but damn sure looked like it when I first got there), hence the chances of him re-coding are significant b/c of the cardiorespiratory depressive effects of his narcotic OD. I may have truly NOT felt a pulse because he was so hemodynamically collapsed that his blood pressure may have been 50/poop, thus no carotid pulse… and PEA. The two minutes of extremely effect compressions could have gotten his blood pressure up just enough for his heart to catch back up. True I had his airway secured, but that is only one component of this very complicated equation, albeit probably the most important one.

        Therapeutic hypothermia would be my goal with the unconscious post-ROSC patient. Why would I want to change this? Suppose the patient did have an overdose, they can figure that out at the hospital. If they laugh at me for treating a patient who had CPR in progress when I arrived, I will deal with it. I have done more embarrassing things than that.

        Narcotic OD codes usually have a 3 part component:
        1) respiratory arrest leading to cardiac arrest,
        2) cardiac arrest precipitated by profound cardiac depression AND/OR
        3) hemodynamic collapse 2/2 histamine release that is accentuated by stimulation of endogenous narcotic receptors within the body.

        Administration of Narcan would counteract the first 2 causes by reversing resp depression, increasing the inotropic activity of heart (yes narcan actual has inotropic properties, I re-looked it up for you , and releasing catecholamines all contributing to improvement of the patient’s hemodynamics. Narcan however does nothing on the massive histamine release that the opioids already did (analogous to a milder version of anaphylactic shock)… that damage is already done. Hence, the further importance of improving his cardiovascular function.

        Do catecholamines really improve cardiovascular function?

        Would phenylephrine have been a better choice for a pressor?

        Would you have given a pressor to this patient, if you had not suspected opioid overdose?

        If you would not have given a pressor, why justify giving naloxone for its catecholamine-stimulating pressor effects?

        So in summary, just because the patient has an “intact airway” says nothing for the rest of him which is still reaming from the effects of his AyRhone. I hope this answered your question.

        Was it heroin, or was it a pill, or is it not known?

        ~Reference: “Naloxone in cardiac arrest with suspected opioid overdoses” by Saybolt, MD, et al.

        I wrote about that paper in April. I was not impressed by their reasoning. This is a small retrospective study, which suggests something to study, but nothing more. It is always good to keep looking at the ways we can improve cardiac arrest outcomes, but I am not optimistic about this treatment.

        Naloxone in cardiac arrest with suspected opioid overdoses

        .

      • EMSDoc911,

        You mention “cardiac depression” and “hemodynamic collapse” as reasons to give naloxone; yet I see no signs of this in the vital signs you’ve presented. Granted, an obese 50 year old will likely have a higher resting pulse and B/P than the 78 and 113/70; but those are good numbers for someone who was recently receiving CPR (even you remarked on how “perfect” his vital signs were).

        I’m aware that opiates and opoids are able to cause cardiac depression, and that I couldn’t see the patient; but the picture you paint could hardly sounds like a patient in danger of re-coding (hell, we should all be lucky enough to get those vitals with ROSC).

        • I will be happy to answer any questions pertaining to my choice on my blog. I’m sorry but I do have an actual job & limited free time to be bouncing around multiple sites. If you have questions, comments or disagreements, feel free to message me directly and/or post on my FB page or blog. https://www.facebook.com/EMSDoc911 or http://emsdoc911.blogspot.com/

          • EMSDoc911,

            On your Facebook page, you wrote –

            @Rogue Medic: sigh…. No offense man, but I think you need to take a course in physiology, just because you can read a paper & cite it doesn’t necessarily mean you understand it… sorry to be brash, but from reading your explanation it is clear to me you have no idea what you are talking about.

             

            I asked for some details.

            You might try to point out the things you claim that I do not understand, rather than just claim that I do not know what I am discussing.

            Do you know what you are writing about, or do you just respond with sigh…you don’t know what you are talking about?

            I recognize that work interferes with internet time, but you have posted five other comments on that thread since then.

            .

  2. Unless we know for sure that this pt’s cardiac arrest was caused by an overdose on opiates and ONLY opiates, I can’t think of any good reason to give this patient naloxone, especially in the prehospital setting.

    This pt is a 50 year old male … Even without knowing his past medical history, there are numerous things that could have caused this patient to arrest. Opiate overdose is only one of them. Also, many patients that have overdosed on opiates have also taken other drugs, such as benzodiazepines or TCAs … Reversing the effect of the opiates in these situations is likely to be of little to no benefit.

    The patient is intubated and being ventilated, so in the case that this is an opiate OD, we have solved the problem of respiratory depression and airway compromise. We are told that the patient has a pulse, although we are not told whether or not he is hemodynamically stable. Again, based on the information available we are NOT 100% certain this is an opiate overdose. If the arrest was due to some other cause, the naloxone will NOT benefit the pt in any way … Yet we have other ways of improving patients’ hemodynamic status. Why not administer a fluid challenge, and vasopressors if needed?

    It would take a lot more than pinpoint pupils to convince me to give naloxone to an intubated patient.

    • Elaina,

      The post-arrest, pre-naloxone vital signs are given.

      BP 113/70, pulse 78

      These suggest that the patient is stable.

      Catecholamine release due to naloxone could make the patient less stable, but not more stable.

      We need better awareness of the potentially harmful physiologic effects of the drugs we give, such as the effects of naloxone on the heart of a resuscitated patient.

      It would take a lot more than pinpoint pupils to convince me to give naloxone to an intubated patient.

      My protocols state –

      Naloxone should not be given to patients that have been intubated.

      Altered Level of Consciousness
      Pennsylvania Statewide Advanced Life Support Protocols
      7002A – ALS – Adult
      page 97/128
      Page with links to PDF downloads of protocols

      Where is the benefit to giving naloxone to the intubated patient?

      Is saving 5, or 10, or 15 minutes of bagging that important?

      Fortunately, things worked out for the patient, but if things had been different –

      Would playing with a 250 pound agitated/violent patient in the back of an ambulance be a good idea? The police are not far behind the ambulance, but they are not in the ambulance and the patient is not restrained.

      This patient was stable, but the drug could have made him become unstable.

      Given the information available at the time, was that a good idea?

      .

  3. So I’m glad that has been settled. Naloxone is not necessary.

    Maybe we should take a physiology class, Rogue?

    • CCC,

      So I’m glad that has been settled. Naloxone is not necessary.

      That is the position of the authors of the ACLS text.

      Naloxone has no role in the management of cardiac arrest.

      Opioid Toxicity
      2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
      Part 12.7: Cardiac Arrest Associated With Toxic Ingestions
      Free Full Text from Circulation

      Maybe we should take a physiology class, Rogue?

      That is what some people tell me about epinephrine for cardiac arrest, antiarrhythmics for cardiac arrest, antiarrhythmics for chest pain, furosemide for CHF, nitrates for CHF, Trendelenberg position for hemorrhage, and plenty of other treatments that work in the classroom, but not in the patient.

      Physiology does not accurately and consistently predicts patient outcomes. If it did, drug companies would not have to do so much research on patients. Physiology is helpful, but there is a tremendous amount that is assumed that should not be assumed.

      Physiology is multifaceted and we tend to simplify things to what we think matters. Then we look foolish when our assumptions are found to be not just wrong, but deadly.

      We should avoid being deadly just to feel that we are following the pfysiology.

      .

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