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

- Rogue Medic

The Kitchen Sink Approach to Cardiac Arrest

 
When faced with death, we can become desperate, stop thinking clearly, and just try anything.

Alternative medicine thrives on the desperation of people who are not thinking clearly. We should be better than that, but are we?

A recent comment on The Myth that Narcan Reverses Cardiac Arrest[1] proposes that I would suddenly give kitchen sink medicine a try, if I really care about the patient.

Kitchen sink medicine? It’s better to do something and harm the patient, than to limit treatment to what works. Throw everything, including the kitchen sink, at the patient.

Mike Karras writes –
 

I will leave you with this question sir and I am interested to hear your answer. You walk in to find your 14 year old daughter that intentionally overdosed on morphine in a suicide attempt and she is in cardiac arrest. How would you treat her? Would you give her Narcan? I think you would.[2]

 

Mike, I am thrilled to read that you do not think that I care about the outcomes of my patients, unless the patient happens to be my daughter. I am even more thrilled that you made my imaginary daughter suicidal.

No, I would not use naloxone (Narcan).

I would also not use homeopathy, acupuncture, sodium bicarbonate, incantations, or magic spells to treat my daughter during cardiac arrest. Voodoo only works on believers, because voodoo is just a placebo/nocebo.[3]
 


Image credit.
 

Does really wanting something to be true make it true? If you believe in magic, the answer is Yes, believing makes it true. If you examine the evidence for that belief, you have several choices. You can acknowledge your mistake, or you can employ a bit of cognitive dissonance, or . . . . Cognitive dissonance is the way our minds copes with the conflict, when reality and belief do not agree, and we choose to reject reality.[4]

According to the ACLS (Advanced Cardiac Life Support) guidelines –
 

Naloxone has no role in the management of cardiac arrest.[5]

 

If the patient is suspected of having a cardiac arrest because of an opioid overdose (overdose of heroin, fentanyl, morphine, . . . ), the treatments should include ventilation and chest compressions. If those do not provide a response, epinephrine (Adrenaline in Commonwealth countries) is added.

An opioid overdose can produce respiratory depression and/or vasodilation. I can counter both of those with chest compressions, ventilation, and maybe epinephrine. Naloxone works on opioid receptors. What does naloxone add?

Does naloxone’s stimulation of an opioid receptor produce more ventilation than bagging/intubating?

Does naloxone’s stimulation of an opioid receptor produce more oxygenation than bagging/intubating?

Does naloxone’s stimulation of an opioid receptor produce more vasoconstriction than chest compressions and epinephrine?*

Also –
 

Don’t confuse post- or pre–arrest toxicologic interventions with the actual cardiac arrest event.[6]

 

Dead people do not respond to treatments the same way living people do.
 
 

See also –
 

Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions – Tue, 01 Nov 2011

Naloxone in cardiac arrest with suspected opioid overdoses – Thu, 05 Apr 2012

The Myth that Narcan Reverses Cardiac Arrest – Wed, 12 Dec 2012

Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest – Sun, 03 Aug 2014
 

* Late edit – 02/17/2015 10:52 – added the word naloxone’s to the three sentences about the relative amount of stimulus provided by standard ACLS and by the addition of naloxone. Thanks to Brian Behn for pointing out the lack of clarity.

Footnotes:

[1] The Myth that Narcan Reverses Cardiac Arrest
Wed, 12 Dec 2012
Rogue Medic
Article

[2] Comment by Mike Karras
The Myth that Narcan Reverses Cardiac Arrest by Rogue Medic
Mon, 16 Feb 2015
Article

[3] Nocebo
Wikipedia
Article

A nocebo is an inert agent that produces negative effects. What this means is that nocebo effects are adverse placebo effects. There is no reason to believe that placebos only produce positive effects or no effects at all.

[4] Cognitive dissonance
Wikipedia
Article

[5] Opioid Toxicity
2010 ACLS
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

[6] 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

Read the whole article about antidotes and cardiac arrest.

.

Comments

  1. [Set: stone steps in ancient Greece. A group of students are gathered around an older man with a long white beard. Heated discussion is underway.]

    Student: “Hippocrates, if it was your child on the floor and you know that she had ingested poppy seeds would you treat her with blown breaths or pray to the Gods?”

    Hippocrates: “Students, who will be the first to describe to me the importance of first doing no harm.”

    Narrator: Thus, the trope of “If it was your kid….” was born and passed forward from generation to generation of medic students.

    [End scene]

  2. We have all seen the reports of how positive pressure ventilation can negatively affect the heart, circulation, and resuscitation efforts. I prefer my patients to be brought in breathing on their own. Here is my thought process and I would like to know where you think the error is in my thought process. A pt (non opioid addicted) overdoses on opioids causing respiratory depression/arrest causing hypoxia, and cardiac arrest. Narcan with CPR and epi in this patient reverses the respiratory depression allowing the pt to breath on their own and thus fixing hypoxia and the pt heart now is able to beat on its own. With your suggestion, every patient you have that is an opioid overdose will be brought into the hospital with positive pressure vent. The only difference in my patient is that my patient has the opportunity to be brought in breathing on their own, your patient will never have this happen. Do you believe that Narcan can cause a negative effect in this patient? If so what is the negative effect and can you please provide me with a link to any study where this has actually occured. Lastly, I didn’t say anywhere that you don’t care about the outcome of your patients. The reason I brought up “your daughter” has to do with the treatment being provided. I think there are people that when treating a family member might not follow their algorithm to the letter if they believed they could do a treatment that would give their family member a better chance (like the example of using Narcan in this scenario). I read all you write and do value your knowledge, experience, and opinions. I wanted to hear your true opinion on the treatment not factoring in legalities with algorithms or what ACLS says.

    • Mike Karras,

      We have all seen the reports of how positive pressure ventilation can negatively affect the heart, circulation, and resuscitation efforts.

      Yes.

      That is why we should only be using positive pressure ventilation for patients who have a respiratory cause of cardiac arrest or for children.

      Since this patient should be a suspected respiratory cause of cardiac arrest (cyanosis and/or other clues are usually present), we should already be using positive pressure ventilation. Even though there are negative consequences of positive pressure ventilation, we cannot avoid positive pressure ventilation on this patient.

      I prefer my patients to be brought in breathing on their own.

      So do I, but there is no reason to believe that adding naloxone (Narcan) to the treatment of cardiac arrest secondary to opioid overdose will do anything to result in the patient arriving at the hospital alive or breathing on their own.

      Narcan with CPR and epi in this patient reverses the respiratory depression allowing the pt to breath on their own and thus fixing hypoxia and the pt heart now is able to beat on its own.

      No.

      Provide some valid evidence to support your claim that there is any improvement with naloxone.

      I wrote about the Saybolt and Koller studies here –

      Naloxone in cardiac arrest with suspected opioid overdoses – Thu, 05 Apr 2012

      Resuscitation characteristics and outcomes in suspected drug overdose-related out-of-hospital cardiac arrest – Sun, 03 Aug 2014

      I made it clear that we should not use naloxone in cardiac arrest outside of controlled research.

      Yes, we should study naloxone, but we do not have any valid evidence to suggest any benefit in cardiac arrest.

      There is no evidence that any of the patients had any respiratory drive at any point after naloxone.

      One patient did survive to discharge, but there is no information about the condition of the patient. The patient could have been discharged neurologically intact or could have been discharged to a long term care facility on a ventilator. We do not know.

      With your suggestion, every patient you have that is an opioid overdose will be brought into the hospital with positive pressure vent.

      With your suggestion, giving naloxone, every patient you have that is an opioid overdose will be brought into the hospital with positive pressure vent. There is no good reason to think that naloxone will change that.

      How does naloxone cause dead people to breathe? Provide some valid evidence.

      Do you believe that Narcan can cause a negative effect in this patient?

      Naloxone distracts the people treating the patient from things that actually work. If there were a benefit, it would be acceptable to give naloxone, but there is no known benefit from naloxone in cardiac arrest due to opioid overdose.

      All treatments have side effects, so we should only use treatments that can be shown to improve outcomes, except during controlled research.

      The reason I brought up “your daughter” has to do with the treatment being provided. I think there are people that when treating a family member might not follow their algorithm to the letter if they believed they could do a treatment that would give their family member a better chance (like the example of using Narcan in this scenario).

      I know why.

      I see the same thing from the quacks pushing alternative medicine. We need to avoid their sloppy thinking.

      If I care about someone, I should be even less likely to resort to magical thinking.

      If I want the best outcome possible, I should stick to what works. If I want the best outcome possible, I should not make excuses to just do something harmful.

      Magic is just something to make us feel better about what we are doing, but it harms our patients for no benefit to the patient. It is just a psychological benefit to those treating the patient (those harming the patient).

      I read all you write and do value your knowledge, experience, and opinions. I wanted to hear your true opinion on the treatment not factoring in legalities with algorithms or what ACLS says.

      Thank you, but I agree with what ACLS says in this case.

      Factoring in legalities? Where did I mention anything about legalities?

      I try to do as little harmful to my patients because I understand that we often harm patients with our lack of understanding of the unintended consequences of our actions.

      The more we understand about what we do to patients, the more we realize how little is beneficial and how much is harmful.

      .

    • Narcan with CPR and epi in this patient reverses the respiratory depression allowing the pt to breath on their own and thus fixing hypoxia and the pt heart now is able to beat on its own.

      The patient will not breathe on their own prior to ROSC, no matter how much Narcan you give them. The first goal is to achieve ROSC, and the only proven way to do this is with quality chest compressions and defibrillation, and ventilations in cases like these where there is a respiratory cause for the arrest. There is no evidence that giving Narcan will lead to ROSC.

      You fix the hypoxia with positive pressure ventilations. This is the only way to fix the hypoxia, and it will work whether you give Narcan or not. Narcan alone will not do it, and will not even contribute to fixing the hypoxia during the arrest.

      There may be a place for Narcan in these cases post-arrest, when there is a possibility of achieving spontaneous respirations, but as far as I am aware even there the evidence is thin, at best (I assume that Rogue Medic knows more on this than I do).

      Simply put, Narcan has no place in cardiac arrest because the cardiac arrest itself is preventing the response we are trying to get from the Narcan – spontaneous respirations.

      Get a pulse back, first. Then worry about respirations.

      • Jake,

        Thank you.

        Following ROSC, we need to consider the likelihood of therapeutic hypothermia in the hospital, for which the patient will be sedated.

        ACLS encourages us to sedate patients to avoid possible reperfusion injury to the brain.

        The research is far from clear, but ACLS Part 9: Post–Cardiac Arrest Care does not even mention giving naloxone (Narcan) as a bolus, a series of tiny boluses, or as a drip to wake up the patient who arrested from an opioid overdose.

        Patients with post–cardiac arrest cognitive dysfunction may display agitation or frank delirium with purposeless movement and are at risk of self-injury. Opioids, anxiolytics, and sedative-hypnotic agents can be used in various combinations to improve patient-ventilator interaction and blunt the stress-related surge of endogenous catecholamines.

        There is no evidence cited for that recommendation, but it does suggest that waking the patient up, right after resuscitation, is not the right thing to do.

        .

  3. My approach since I began as a Medic not too long ago, is to do as much for the patient with as little as possible. Drives me nuts when folks question me because I have not given them everything in my drug bag.

  4. I do not have the researching skills you do but I’m curious to see what you find on this link I was given by a firefighter friend in N.Y. I was told both patients were codes and only given cpr and narcan.
    http://www.ems1.com/bystanders/articles/2096310-EMTs-save-2-with-Narcan-after-they-were-pulled-from-burning-car/

    • The article states that they were unconscious.

      It would be interesting to know more about what happened, but this is an anecdote and should not be used as the basis for treatment.

      Naloxone is known to reverse respiratory depression in living people. We do not even know if they unconscious because of opioid overdose or some other cause. One of the problems with naloxone administration is that we too often assume that a response after naloxone is a response because of naloxone.

      Six of the 25 complete responders to naloxone (24%) ultimately were proven to have had false-positive responses, as they were not ultimately given a diagnosis of opiate overdose. In four of these patients, the acute episode of AMS was related to a seizure, whereas in two, it was due to head trauma; in none of these cases did the ultimate diagnosis include opiates or any other class of drug overdose (which might have responded directly to naloxone). Thus, what was apparently misinterpreted as a response to naloxone in these cases appears in retrospect to have been due to the natural lightening that occurs with time during the postictal period or after head trauma.

      The empiric use of naloxone in patients with altered mental status: a reappraisal.
      Hoffman JR, Schriger DL, Luo JS.
      Ann Emerg Med. 1991 Mar;20(3):246-52.
      PMID: 1996818 [PubMed – indexed for MEDLINE]

      http://www.ncbi.nlm.nih.gov/pubmed/1996818

      .

  5. I’m in the process of trying to get a hold of one of the guys on MFD Engine 7 to hear exactly what happened I’ll let u know sir

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