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

- Rogue Medic

Is First Responder Narcan the Same as First Responder AED?


Image credit.
 

Are these the same?

If one works, does the other work?
 


Image credit.
 

The idea that first responders can safely give naloxone (Narcan) is popular, but only based on things that we want to be true. Dr. Oz would love it.

It has been suggested that giving first responders naloxone is the same as giving them AEDs (Automated External Defibrillators).[1] AEDs are defibrillators that can deliver the same shock as a manual defibrillator, but AEDs do not require all of the education needed to become a paramedic, nurse, PA, NP, or doctor.

Unlike naloxone, AEDs are designed to do almost all of the assessment for the first responder. The AED is only supposed to be attached to a pulseless patient, so assessment for responsiveness and the presence of a pulse is expected by the first responder. Is naloxone assessment that simple?

When a patient actually has an opioid overdose, it can be that simple, but –

Not all patients who respond after naloxone, respond because of naloxone.

This is the concept that is difficult to explain to the advocates of first responder naloxone programs.

1. Some advocates deny that this happens, even though it is documented.

2. Some advocates claim that we already know all that we need to know about naloxone.

3. Some advocates also claim that we should not study this because we already know all that we need to know.

Since there is overlap among the groups, the failure to understand the problem of improper assessment, especially among paramedics, nurses, and doctors is a huge problem. If we do not understand naloxone, with all of our education in pharmacology, how can we expect first responders to understand naloxone without any education in pharmacology?

What kind of education can prevent mistakes? How do we know?

If we listen to those who don’t know, but claim that they know all that they need to know, we will be ignoring the possibility of unintended consequences and assuming that we are too smart to make mistakes. Is that reasonable?

Do AEDs save lives?
 

CONCLUSION:

Addition of AEDs to this EMS system did not improve survival from sudden cardiac death. The data do not support routinely equipping initial responders with AEDs as an isolated enhancement, and raise further doubt about such expenditures in similar EMS systems without first optimizing bystander CPR and EMS dispatching.[2]

 

The problem is not that AEDs do not work.

The problem is not that AEDs are not safe.

The problem is thinking that AEDs are a simple solution to a problem that is not as simple as some would like us to believe.
 

The concept of equipping as many emergency responders as possible with AEDs has been widely adopted,2 and 31 but it should not be blindly adopted without improving the EMS system at all levels. This decision should be individualized to each EMS system based on all of the variables in EMS response. As an isolated enhancement, it is doubtful that addition of AEDs will provide a measurable survival benefit.[2]

 

If first responder naloxone were limited to people found with needles in their arms, less thought would be required. As the presentation of overdose changes to prescription opioids, there is less clear evidence of overdose and more of a need for a good assessment and understanding of pharmacology.

First responder naloxone may save lives, when it is administered appropriately. We should study this before implementation. Discouraging us from studying the safety and efficacy of this type of use of naloxone is bad medicine.
 

Also see –

Is ‘Narcan by Everyone’ a Good Idea?

Should Basic EMTs Give Naloxone (Narcan)?

The Myth that Narcan Reverses Cardiac Arrest

To Narcan or not Narcan

What About Nebulized Naloxone (Narcan) – Part I

Footnotes:

[1] I’ve heard that PA is looking to follow down the “Narcan for everyone” route, in allowing PD and BLS folks to give intranasal naloxone. . . .
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Narcan post

[2] EMT defibrillation does not increase survival from sudden cardiac death in a two-tiered urban-suburban EMS system.
Sweeney TA, Runge JW, Gibbs MA, Raymond JM, Schafermeyer RW, Norton HJ, Boyle-Whitesel MJ.
Ann Emerg Med. 1998 Feb;31(2):234-40.
PMID: 9472187 [PubMed – indexed for MEDLINE]

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Comments

  1. An AED, even if applied without proper assessment for a pulse, will not deliver a shock on a patient who is not in ventricular fibrillation or ventricular tachycardia. That means that even allowing for shortcomings in untrained individuals’ assessment skills, the AED cannot injure someone or be used inappropriately, unless it is used as a club to hit someone over the head.

    Conversely, even while Naloxone is not (generally-speaking) a dangerous medication to give, it can be used inappropriately in conjunction with a poor assessment. As you repeatedly say, we have enough problems with EMTs, Paramedics, Nurses, and physicians using Naloxone inappropriately, and those individuals are highly-trained medical professionals.

    I am 100% on board with the family members of known opioid addicts being permitted to receive Naloxone, either auto-injectors or mucosal atomizers. Generally-speaking, these people know what they’re dealing with. For the average police officer, first-responder, etc. I’d feel better about giving them a bag-valve mask, a couple of nasal airways, and teaching them how to use them. Those skills, at least, would be useful in situations OTHER than acute opioid overdose, are probably MUCH cheaper than issuing Naloxone, and would allow those first-responders to do what the patient needs most: ventilations.

    As your banner so loudly states (and perhaps my favorite Rogue Medic-ism): “If you have a bag-valve mask, you should not need Naloxone. The problem is inadequate inspiration, not inadequate Naloxonation.”

    • Windy City Medic,

      I agree.

      However, I may have to change that to If you have a bag-valve mask, and the skill to use it, you should not need Naloxone. The problem is inadequate inspiration, not inadequate Naloxonation.

      I criticize others for ignoring reality, so I should acknowledge that bit of reality.

      .

      • Indeed. We also have plenty of EMTs, Paramedics, Nurses, Respiratory Therapists, and Physicians who don’t know how to use a bag-valve mask. But I think it would probably be easier to teach proper ventilation with a BVM than it would to teach the proper indications and contraindications for the administration of Naloxone. It’s pretty simple:

        1. Is the patient breathing? If no, proceed to step two.
        1a. Is the patient breathing more than ten times a minute? If no, proceed to step two.
        1b. Is the patient the color of blueberry pie? If yes, proceed to step two.
        2. Give ventilations with the bag-valve mask.

    • I forgot to specify: the reason I believe in giving Naloxone to family members of known addicts and not to first responders is that for those family members, the use of Naloxone is not ALWAYS going to be followed by a request for EMS or with further medical evaluation. The family may give the Naloxone, wake the person up, allow them to vomit, and then leave them be while they go through withdrawal. Conversely, the average police officer, first-responder, etc. is almost ALWAYS going to be requesting EMS and transferring care. The first-responder or police officer only needs to keep the patient from dying while they await the arrival of EMS.

      Much as family members of diabetics, who will pour pancake syrup or oral glucose down their family member’s throat when their sugar drops too low, until the patient is awake and coherent enough to sit down and eat a meal. EMS is not always summoned in these situations.

  2. This is stupid.

  3. Liked Anonymous reply “This is stupid”

    See the video hyper linked under my name. Watch 1st minute then 4:40 seconds. Chest compressions only to his childhood friend who is a six foot “blueberry pie”

    Then an article from The Lancet 383(9933)1957-8. June 7, 2014. Quote “One of the attendees ran in to tell her (an RN) someone was dying just a few blocks away and needed a dose of Naloxone. “I just gave it to him and said come back and let me know what happens….” What was this clinician thinking leaving someone apparently dying a respiratory emergency a few blocks away.

    This one for the books CJPH 2013;104(3)e200-4 Protocol steps naloxone, chest compressions. Three to five minutes later more naloxone and continue chest compressions till EMS arrives. Chest compressions printed on a nice “Blueberry” background.

    My reply to Anonymous et al
    Tis crazy

    • gary thompson,

      Liked Anonymous reply “This is stupid”

      It is too bad that Anonymous has not told us what Anonymous considered stupid. Why do you agree with someone when you do not know what the person means.

      This is stupid.

      This could mean the discussion.

      This could mean giving naloxone to first responders.

      This could mean not giving naloxone to first responders.

      This is stupid could be irony from a troll – This (this comment) is stupid.

      We cannot tell, because Anonymous does not tell us what is intended.

      See the video hyper linked under my name. Watch 1st minute then 4:40 seconds. Chest compressions only to his childhood friend who is a six foot “blueberry pie”

      I don’t see anything about first responder naloxone in the video. Someone refers to the bystanders as first responders, but first responder refers to the first professional responders on scene (police, fire, EMS).

      You appear to be criticizing the bystander for not having medical training. Bystanders are not first responders (the subject of what I wrote). What is your point?

      Then an article from The Lancet 383(9933)1957-8. June 7, 2014. Quote “One of the attendees ran in to tell her (an RN) someone was dying just a few blocks away and needed a dose of Naloxone. “I just gave it to him and said come back and let me know what happens….” What was this clinician thinking leaving someone apparently dying a respiratory emergency a few blocks away.

      Again, this is not relevant to first responder naloxone.

      I do not see why you claim to know what is best for the patients the nurse was already taking care of – patients you seem to think the nurse should abandon because somebody came in and told her something.

      The article tells us nothing about the patients, yet you appear to assume that you know.

      This one for the books CJPH 2013;104(3)e200-4 Protocol steps naloxone, chest compressions. Three to five minutes later more naloxone and continue chest compressions till EMS arrives. Chest compressions printed on a nice “Blueberry” background.

      Here is what is written in the article. Perhaps if you were to read what you are commenting on, you would understand why the choice to include chest compressions was made.

      Giving naloxone to a pulseless patient is not a good idea. Is that what you are advocating?

      Naloxone is not in the ACLS algorithms as a treatment for cardiac arrest. Naloxone is explicitly discouraged.

      The program’s resuscitation protocol has come under scrutiny for its decision to include chest compressions but exclude mouth-to-mouth ventilations, as most other naloxone programs teach a rescue protocol incorporating ventilations without chest compressions. This highlights uncertainties related to the optimal approach to the bystander resuscitation of suspected opioid overdose victims. Respiratory depression is an important component of opioid overdose.26 However, the POINT’s rescue protocol is based on the assertions that 1) first responders are unable to identify unresponsive pulseless patients reliably, (27) 2) naloxone administration has no role in cardiac arrest (including those due to opioid overdose), (26) 3) ventilations may complicate bystander resuscitation, making it harder to teach, learn, execute and perform under challenging circumstances, (28) and 4) significant numbers of opioid-related deaths involve polysubstance overdose with cardiotoxic drugs. (29) Painful stimulation (such as chest compressions) may be an effective means of increasing respiratory drive. (30) Additionally, failure to provide continuous chest compressions to overdose patients in cardiac arrest constitutes a failure to provide basic resuscitative necessities. Attempting to teach both ventilations and chest compressions can complicate bystander resuscitation without providing a demonstrable benefit. Enhancing collaboration between resuscitation science and harm reduction experts might generate basic life support guidelines for lay rescuers attending to opioid overdose with naloxone.

      The authors are correct when they cite the ACLS Guidelines –

      Naloxone has no role in the management of cardiac arrest.

      Opioid Toxicity
      Part 12: Cardiac Arrest in Special Situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
      Part 12.7: Cardiac Arrest Associated With Toxic Ingestions
      Terry L. Vanden Hoek, Laurie J. Morrison, Michael Shuster, Michael Donnino, Elizabeth Sinz, Eric J. Lavonas, Farida M. Jeejeebhoy, and Andrea Gabrielli
      Circulation. 2010;122:S829-S861, doi:10.1161/CIRCULATIONAHA.110.971069
      http://circ.ahajournals.org/content/122/18_suppl_3/S829.full#sec-83

      Read the discussion and perhaps you will understand that this is more complicated than you seem to suggest.

      My reply to Anonymous et al
      Tis crazy

      Do you mean that your comment is crazy, that giving naloxone to first responders is crazy, that the video is crazy, that the first article is crazy, that the second article is crazy, or something else? Please try to be clear about what you mean.

      About the only thing that is really clear from your comment is that you have strong feelings about “blueberry pie”, but it is not clear if you like “blueberry pie”, if you hate “blueberry pie”, or if you have some other strong feeling about “blueberry pie”.

      .

  4. Sorry my meaning behind Anonymous “This is Stupid” have been dealing with “Trolls” in the medical profession to long.

    Layperson in video “Eyes Wide Open” was trained three days earlier my a medical professional.
    Signs of Overdose
    • Can’t wake the person up
    • Breathing is very slow, erratic or has stopped
    • Deep snoring or gurgling sounds
    • Fingernails or lips are blue or purple
    • Body is very limp
    • Pupils are very small
    Have talked with WR Crime Prevention people repeatedly Since 2011 and the nurses and doctors teaching this protocol
    1) Shake at shoulders, Shout their name
    2) Call 911 if unresponsive
    3) Naloxone Inject 1 ampule (1cc. 0.4mg) of Naloxone into arm or leg muscle
    4) Chest Compressions Push hard and fast on the centre of the chest
    5) Is it working? If no improvement after 3-5 minutes, inject a 2nd ampule (1cc. 0.4mg) of Naloxone and continue with chest compressions until EMS arrives

    This training to laypersons is 30 minutes long, one on one, no mention of respiratory assist in webinar, nor during training. I took this training Sept 2, 2011 asked about respiratory assist was told “chest compressions only is the new standard”

    TPH training Webinar http://www.instantpresenter.com/ohtn/E956D7808049 Slide 31

    TPH training video http://www.youtube.com/watch?v=zlbkU5IK5Do I know all three personally the people in the video they are making themselves sick teaching this. Non OD deaths have occurred responders were doing as taught. 20% of the time people leave their naloxone elsewhere and the patients are getting chest compressions only.

    Have letter from the authors of ILCOR & AHA guidelines 2010. One of whom wrote this protocol?
    Every medical authority tells me go after Toronto Public Health.
    http://www.linkedin.com/pub/gary-thompson/74/b80/923/

    “Patty now completely blue around the gills slid quietly under the table and everyone PRETENDED NOT TO NOTICE”

    Don’t particularly like squished Blueberry Pie

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