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

Safety of Intranasal Fentanyl in the Out-of-Hospital Setting – A Prospective Observational Study

ResearchBlogging.org
 
I have been very critical of plans to have first responders treat people they suspect of having a heroin (or other) opioid overdose with naloxone.

Would first responders be safer with fentanyl?

It is not really the same question, but it does highlight the differences and why I think fentanyl is safer. The patient will be seen by someone more likely to recognize when the treatment is inappropriate. This study looked at IN (IntraNasal) fentanyl given by basic EMTs prior to transport to the ED (Emergency Department).
 


Image credit.
 

Previous studies demonstrate adverse effects in 3.3% to 39% of patients treated with intranasal fentanyl,3, 4 and 5 providing an ambiguous safety profile.[1]

 

The concentration of fentanyl (Instanyl in this study) is different from what I have available. They use 500 µg/ml, while I only have fentanyl in a concentration of 50 µg/ml. Ten times the volume does make measurement easier, but ten times the volume may impair absorption.
 

The atomizer contains a single dose with a prefixed quantity of either 50 μg (500 μg/mL) or 100 μg (1,000 μg/mL) fentanyl and has a dose volume of 0.1 mL (lower than the 0.15 mL limit necessary to avoid pharyngeal runoff7). The Instanyl preparation contains fentanyl in no other recipients than purified water and a phosphate buffer to match the physiologic environment of the nasal cavity and to increase bioavailability.9 [1]

 

Patients were not limited to healthy trauma patients, so these results can be generalized to a variety of patients.
 

We administered 50 μg to patients younger than 18 years, older than 65 years, with chronic obstructive pulmonary disease, or who were considered generally weakened or malnourished by the attending paramedic/EMT. All others received 100 μg. In patients reporting insufficient analgesia, the initial dose could be repeated once or twice after 10 and 25 minutes, respectively.[1]

 


 

The smaller decrease in level of pain suggests that they were more cautious in administering fentanyl to the comorbid patients.

The time between doses did lead to some extended scene times (first dose at 0 minutes, second dose at least 10 minutes later, and the third dose at least 35 minutes after the first dose), but that is usually preferable to causing extreme pain by moving the patient with inadequate pain management, regardless of the proximity of the hospital.
 


 

What many people fail to realize, doctors included, is that the hospital may only be five minutes away after we are in the ambulance, but we need to manage the pain before we move toward the ambulance. When I call for orders to give more pain medicine than I can give on standing orders, medical command doctors sometimes ask how far away from the hospital we are. I respond that it depends on when the pain is managed. Unless there is some medical condition that requires us to move the patient more quickly, we should move the patient only when the patient feels the pain is managed.
 

How effective was the intranasal fentanyl at managing pain?
 

I would prefer to lower the level of pain by more than they did, but I am accustomed to giving IV (IntraVenous) fentanyl, so I am able to titrate it more accurately.
 


 

Patients received 1 (n=526), 2 (n=333), or 3 (n=44) doses of fentanyl, with a mean cumulative dose of 114 μg.[1]

 

Fewer than 5% of patients required more than two doses.

They did give a variety of total doses of fentanyl. The result seemed to be similar regardless of the total dose. This could indicate that fentanyl is just a placebo (unlikely) or that the EMTs did a good job of titrating the medicine to the response.
 


 
 

This was a safety study, so how safe was intranasal fentanyl?
 

The criterion for hypotension is a bit different from what I am accustomed to. Even using MAP (Mean Arterial Pressure), I have not considered patients to be hypotensive above a MAP of 60.
 

We calculated the mean arterial pressure (MAP) and defined hypotension as a MAP reduction greater than or equal to 10 mm Hg and an end MAP less than or equal to 70 mm Hg.14 [1]

 

How much respiratory depression and hypotension did they have?
 

We did not observe respiratory depression (respiratory rate less than 11 breaths/min), GCS score reduction to 14 in 5 patients was transient, and there was no use of naloxone or mask ventilation. Ten patients (1%) had measurable hypotension; however, none experienced syncope and only 1 experienced dizziness, suggesting that these events were of low clinical importance. Indeed, pain relief may be partially responsible for the decrease in MAP.[1]

 

Studies repeatedly show that fentanyl can be given safely to hypotensive patients and half of the hypotensive patients were no longer hypotensive after fentanyl was given in one prehospital trauma study.[2] This suggests that a fluid bolus may be less effective than fentanyl at getting rid of hypotension.
 

As pointed out by O’Donnell et al,20 out-of-hospital undertreatment of pain in pediatric patients may be due to safety concerns. Our study supports the safety of intranasal fentanyl in children.[1]

 

Fentanyl is even safe in children and safe in adults with comorbidities even when given by basic EMTs.

It seems that fentanyl is safe and much more effective than not treating the pain. Is IN fentanyl more effective than other pain medicines? We still do not know.

Footnotes:

[1] Safety of intranasal fentanyl in the out-of-hospital setting: a prospective observational study.
Karlsen AP, Pedersen DM, Trautner S, Dahl JB, Hansen MS.
Ann Emerg Med. 2014 Jun;63(6):699-703. doi: 10.1016/j.annemergmed.2013.10.025. Epub 2013 Nov 22.
PMID: 24268523 [PubMed – in process]

[2] Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia.
Krauss WC, Shah S, Shah S, Thomas SH.
J Emerg Med. 2011 Feb;40(2):182-7. Epub 2009 Mar 27.
PMID: 19327928 [PubMed – in process]

Full Text PDF Download at medicalscg.

My review of this paper –

Fentanyl in the out-of-hospital setting: variables associated with hypotension and hypoxemia
Fri, 27 May 2011
Rogue Medic
Article

Krauss, W., Shah, S., Shah, S., & Thomas, S. (2011). Fentanyl in the Out-of-Hospital Setting: Variables Associated with Hypotension and Hypoxemia The Journal of Emergency Medicine, 40 (2), 182-187 DOI: 10.1016/j.jemermed.2009.02.009

Karlsen AP, Pedersen DM, Trautner S, Dahl JB, & Hansen MS (2014). Safety of intranasal fentanyl in the out-of-hospital setting: a prospective observational study. Annals of emergency medicine, 63 (6), 699-703 PMID: 24268523

.

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. . . .
Facebook
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]

.

Is ‘Narcan by Everyone’ a Good Idea?


Image credit.
 

My friend Jonathan Blatman asks the following question about naloxone (Narcan) on Facebook –
 

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

 

The problem is not that basic EMTs, or first responders, or police are stupid people.

The problem is that all people are stupid people.

Doctors, nurses, and paramedics do not understand naloxone, so we need to improve the understanding of pharmacology among doctors, nurses, and paramedics, before we increase the ranks of ignorant people inappropriately administering the drug.

Naloxone itself is very safe.

A quack once challenged me to take 1,000 times the dose of any medicine I chose, while he would do the same with some natural product. I accepted and chose naloxone, with the condition that he first take 1,000 time the daily recommended dose of one of something he considered completely safe and natural – water.

The quack had it pointed out to him that this dose of all natural water would be deadly. The quack backed out. Whether naloxone’s standard dose is 0.4 mg (it should not be more than this) or the dose more popular in areas with frequent fentanyl overdoses (2.0 mg) does not matter. Naloxone has been demonstrated to be relatively safe at massive doses.
 

Adult Patients
In one small study, volunteers who received 24 mg/70 kg did not demonstrate toxicity.
In another study, 36 patients with acute stroke received a loading dose of 4 mg/kg (10 mg/m2/min) of naloxone hydrochloride injection followed immediately by 2 mg/kg/hr for 24 hours. Twenty-three patients experienced adverse events associated with naloxone use, and naloxone was discontinued in seven patients because of adverse effects. The most serious adverse events were: seizures (2 patients), severe hypertension (1), and hypotension and/or bradycardia (3).
[2]

 

400 mg (0.4 mg dose x 1,000) or 2,000 mg (2.0 mg x 1,000) would be higher than the doses tested in these patients, but would still be much safer than 1,000 times the recommended daily dose of water, even though water is safe and essential for life. It does not matter if there is fluoride in the water for it to be lethal, but we should fluoridate water, because only conspiracy theorists think that fluoride is dangerous in drinking water.
 


Download YouTube Video | YouTube to MP3: Vixy | Replay Media Catcher
 

We engage in magical thinking about the drugs we give.

The problem is not with the drug. The problem is with the actions of the people giving the drug – us.

We still have a big push for giving fibrinolytics (tPA – tissue Plasminogen Activator) to patients with acute ischemic stroke, even though most of the improvement may be due to the transience of stroke symptoms in some stroke patients (TIS – Transient Ischemic Attack). Fibrinolytics do not appear to be beneficial for acute ischemic stroke and there is no reason to give them for a TIA.

There is weak beneficial evidence in only two out of eleven studies (only 18% of studies) – and increases in death in most studies of fibrinolytics for acute ischemic stroke.[3] The problem is not with the drug. The problem is with the actions of the people giving the drug. Most of the evidence shows death increased, but we ignore that.

Naloxone and tPA are both given based on a rush to treatment and a fear of not giving the standard of care – the Yuppie Nuremberg Defense.
 

Everyone’s got a mortgage to pay. [inner monologue] The Yuppie Nuremberg defense.[4]

 

Will this be a matter of providing naloxone, rather than providing ventilations?
 

An epidemic of naloxone-resistant heroin overdoses due to fentanyl adulteration has led to significant morbidity and mortality throughout the central and eastern United States. According to records of the Philadelphia County Medical Examiner’s office, at least 250 overdose deaths have been associated with fentanyl between April 1, 2006, and March 1, 2007.[5]

 

What about people who take more than one drug?

If the opioid is reversed, will there be problems?
 

All were initially lethargic and became agitated and combative after emergency medical service (EMS) personnel treated them with parenteral naloxone, which is routinely used for suspected heroin overdose to reverse the toxic effects of opioids (e.g., coma and respiratory depression). All patients received diazepam or lorazepam for sedation, and signs and symptoms resolved during the next 12-24 hours.[6]

 

Will we identify the patients who have other medical conditions that may respond after naloxone, but not because of naloxone, such as hypoglycemia, stroke, seizures, clonidine overdose, arrhythmia, head trauma, dehydration, syncope, et cetera?
 

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.[7]

 

The problem is not with the administration of naloxone, but with the faulty assumption that because a patient wakes up after naloxone, the patient woke up because of naloxone.

Doctors, nurses, and paramedics do not do a good job of identifying the difference currently. We need to educate them, rather than encourage others to replicate their mistakes.

Pharmacology is poorly understood by people with medical education.
 

The documented indication for nebulized naloxone administration was suspected opioid overdose in 70 patients (66.7%), altered mental status in 34 patients (32.3%), and respiratory depression in one patient (0.9%).[8]

 

The indication for naloxone is respiratory depression.

The treatment for respiratory depression is to supplement oxygen and/or ventilations. We have decided to give naloxone in stead.

Naloxone was used appropriately in fewer than 1% of patients.

How good bad will our naloxone by everyone education be?

Don’t wait with bated breath – someone my administer naloxone.
 

Also read –

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. . . .
Facebook
Narcan post

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

DailyMed
Adverse reactions
Overdosage
FDA Label

[3] The Guideline, The Science, and The Gap
Wednesday, April 17, 2013
Dr. David Newman
Smart EM
Article

[4] Thank You for Smoking
Movie, based on the book by Christopher Buckley
Wikiquote
Quote page

[5] Heroin: what’s in the mix?
Muller AA, Osterhoudt KC, Wingert W.
Ann Emerg Med. 2007 Sep;50(3):352-3.
PMID: 17709054 [PubMed – indexed for MEDLINE]

[6] Scopolamine Poisoning among Heroin Users — New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996
MMWR (Morbidity and Mortality Weekly Report).
Vol 45, No 22;457;
Free Full Text from the Centers for Disease Control and prevention.

[7] 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]

[8] Can nebulized naloxone be used safely and effectively by emergency medical services for suspected opioid overdose?
Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB.
Prehosp Emerg Care. 2012 Apr-Jun;16(2):289-92. doi: 10.3109/10903127.2011.640763. Epub 2011 Dec 22.
PMID: 22191727 [PubMed – indexed for MEDLINE]

.

How Diagnostic is Narcan?

ResearchBlogging.org

At Resus.ME,[1] Dr. Reid suggests that one benefit of nebulized naloxone[2] is its diagnostic value. He asks –

Do you ever use naloxone diagnostically, and if so, do you think it’s worth knowing that the nebulised route is an option?

This has been studied.

our primary hypothesis was that response to naloxone in such patients is almost always predictable on the basis of easily determined clinical characteristics.[3]

For AMS (Altered Mental Status) patients, compared with a very simple exam, does naloxone improve our ability to identify the patients with opioid overdose?

Data collected included the patient’s response to naloxone as well as three specific clinical findings; these findings were respirations, pupil size, and presence or absence of circumstantial evidence of opiate abuse.[3]

Today, the circumstantial evidence is probably going to be present less often due to the increased percentage of abuse of prescription pain pills. If the pill container is not present, or the pill container is not the original labeled container, then this might not be helpful. Since there is less of a need to inject the opioids to produce the high, the presence of track marks, or a needle and a spoon, or other drug paraphernalia, may not be present.

Would that make much difference?

Even more accurate than response to naloxone is a respiratory rate of 12 or less.


Click on image to make it larger.

The hospital charts of all naloxone responders, partial responders, and the sample of nonresponders were reviewed by one of the physician authors to determine whether opiate overdose was included as a discharge diagnosis.[3]

If anything, the response to naloxone would bias the diagnosis toward including opioid overdose in the diagnosis, so the results should have made naloxone look better.

Does a response to naloxone mean that the emergency physician can safely rule out other causes of AMS?

How diagnostically useful is naloxone?

Final diagnoses at discharge from the ED, or the hospital if admitted, were obtained on all 25 responders, 26 of 32 partial responders, and 195 of 673 nonresponders.[3]

That is a lot of naloxone for very little response.

What about nebulized naloxone?
 


Image credit.

For the patients most likely to be breathing well enough to use a nebulizer for naloxone administration (≥13 breaths per minute), does naloxone provide any benefit?

The two patients with opiate overdose who were not identified by these clinical findings did not respond to naloxone,[3]

Only two patients were breathing faster than 12 times per minute, but neither patient responded to IV (IntraVenous) naloxone.

Should we expect them to respond to nebulized naloxone?

Are these two patients in any way representative of the patients breathing adequately enough to use nebulized naloxone?

We should not draw conclusions from such a small group 2 out of 730 patients, but the lack of response to naloxone in both of these patients is not exactly a recommendation for the diagnostic value of naloxone even in the group of patients most likely to receive naloxone by nebulizer.

The study indicates that there is no diagnostic benefit derived from the administration of naloxone to all AMS patients.[3]

This is probably not what Dr. Reid was suggesting, but it is disappointing to know that many of us have continued to give naloxone routinely to AMS (Altered Mental Status) patients, even though we have had good evidence that we could use diagnostic criteria to identify the patients most likely to respond to naloxone since 1991.

While the value of subsequent administration of naloxone in the ED has never been formally analyzed (and cannot be fairly evaluated on the basis of our data), allowing physicians to selectively decide which patients with AMS should receive this drug would undoubtedly retain many of the benefits demonstrated here while allowing medical judgment to determine if any other patients without clear-cut indications might still benefit from its use.[3]

I expect that Dr. Reid is not administering naloxone to every AMS patient he sees, but trying to limit the use to those patients most likely to respond.

If we give naloxone – nebulized, rectally, buccally, subcutaneously, intramuscularly, intravenously, or just massaged into the skin as part of a diagnostic massage – does naloxone diagnose anything?

If the patient is postictal and has an improvement in level of consciousness after naloxone, is that diagnostic?

If the patient had a TIA (Transient Ischemic Attack), or a stroke, and has an improvement in level of consciousness after naloxone, is that diagnostic?

If the patient is diabetic, but responding to dextrose (or to glucagon) slowly, and has an improvement in level of consciousness after naloxone, is that diagnostic? Yes, we should have a blood sugar, but if we are fixated on naloxone . . . .

If the patient had a clonidine overdose and has an improvement in level of consciousness after naloxone, is that diagnostic?

If the patient has consumed alcohol and has an improvement in level of consciousness after naloxone, is that diagnostic?

The answer to all of these appears to be No.

Also see –

Nebulised Naloxone at flobachrepublic.

Narcan Nebs – Why? New research doesn’t say.. at Mill Hill Ave Command.

Footnotes:

[1] Nebulised naloxone
May 14, 2012
by Cliff
Resus.ME
Article

[2] Can Nebulized Naloxone Be Used Safely and Effectively by Emergency Medical Services for Suspected Opioid Overdose?
Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB.
Prehosp Emerg Care. 2011 Dec 22. [Epub ahead of print]
PMID: 22191727 [PubMed – as supplied by publisher]

[3] 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]

Hoffman JR, Schriger DL, & Luo JS (1991). The empiric use of naloxone in patients with altered mental status: a reappraisal. Annals of emergency medicine, 20 (3), 246-52 PMID: 1996818

.

Naloxone in cardiac arrest with suspected opioid overdoses

ResearchBlogging.org

Peter Canning is doing a countdown of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic. Number 15 is Narrower use of Narcan, which is important and an improvement in patient care. The topic did encourage me to write about this study on naloxone (Narcan) in cardiac arrest from suspected opioid overdose.

Can naloxone improve survival from cardiac arrest?

This is an interesting study that looks at some old charts to try to figure out if naloxone made any difference when it was given to cardiac arrest patients suspected of having an opioid overdose. Here is the interesting part of their hypothesis –

Naloxone has been demonstrated to reduce action potential upstroke in guinea pig, canine, rabbit, and sheep myocardium.8,18,19 The inhibition of action potential upstroke is correlated with the inhibition of fast inward sodium currents. In addition, an effect on repolarizing potassium currents has been shown to suppress re-entrant rhythms by prolonging action potential duration and increasing the refractory period.23 Therefore, naloxone’s antiarrhythmic activity appears to be similar to both class I and III antiarrythmics.23 [1]

Amiodarone also has a shotgun effect on the conduction system, just like the person who decides to change all of the settings on a ventilator without waiting to see what any of the effects might be.

Of course, relying on an antiarrhythmic effect is not likely to improve survival, but it is worth studying.

There is no evidence that any antiarrhythmic drug given routinely during human cardiac arrest increases survival to hospital discharge. Amiodarone, however, has been shown to increase short-term survival to hospital admission when compared with placebo or lidocaine.[2]

The result is just more people dying in the hospital, but ROSC (Return Of Spontaneous Circulation – the short-term change that rarely lasts when obtained with drugs) is hard to ignore.

I have pointed out that the addition of naloxone to the ventilation and epinephrine we are already giving is not likely to add any benefit. With respiratory depression/rerspiratory arrest as the suspected cause of cardiac arrest, these patients are some of the minority who may benefit from ventilation and should be ventilated. When the potentially reversible cause is hypoxia/anoxia, ventilation is a part of the treatment.


Click on images to make them larger.

Not a lot of patients, but New Jersey protocols require medical command permission to give naloxone in cardiac arrest, so there is not a lot of dumping of drugs that “couldn’t hurt” and are coincidentally nearing their expiration date.

Changes in original rhythm noted immediately following naloxone administration, but before additional pharmacologic interventions, were defined as immediate changes. Delayed changes were defined as cardiac rhythm changes occurring after additional medications were administered but within a 10-min interval following initial naloxone dose. The primary outcome measure was change in cardiac activity from baseline based upon EKG rhythm. Secondary outcome measures examined included return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge.[1]

If the primary endpoint is a change in rhythm, then it appears that the naloxone is being given as an antiarrhythmic, but it is difficult to measure any effect on anything else naloxone might affect.

Naloxone was never the first drug given, but it was occasionally the last prehospital drug given, because of ROSC.

What were the results?

The charts reviewed were from 01/01/2003 to 12/31/2007, so all of the asystole and PEA (Pulseless Electrical Activity) patients had atropine in the protocol. Only one patient started in VF (Ventricular Fibrillation).

Only one patient survived. A 36 year old female, found in asystole. She received epinephrine two times and atropine two times over a 13 minute period. She remained in asystole. Following medical command orders, she received 2 mg naloxone and converted to sinus tachycardia (130 bpm) within 2 min.

She survived to be discharged at 11 days. No information on neurological function is provided. She may have gone to a nursing home or she may be a brain surgeon. We do not know.

1 out of 36 is just 2.8%. Not very good, but these were patients presenting in asystole/PEA, so nothing good is really expected.

At the end of the paper, the authors switch to claiming that this use of naloxone is somehow reversing opioid-induced histamine release. As if we do not successfully treat histamine release much more successfully with epinephrine.[3] Every patient received epinephrine at least one time in doses much larger than would be used for anaphylaxis prior to receiving naloxone. Anaphylaxis is the most extreme example of a histamine release effect.

If there is a positive effect from naloxone, that would be good to know. Unlike most other drugs used in cardiac arrest, naloxone does not appear to produce any significant harm to the heart or brain when used to treat cardiac arrest.

While we definitely do not want to just make this a part of the treatment algorithms without much better evidence, we should find out if there is any benefit. If naloxone has antiarrhythmic properties, is there any reason to limit the research to suspected opioid overdose? This might be difficult to study prospectively, although the other UMDNJ hospitals would seem to be ideal locations to look for suspected opioid overdose patients.

Footnotes:

[1] Naloxone in cardiac arrest with suspected opioid overdoses.
Saybolt MD, Alter SM, Dos Santos F, Calello DP, Rynn KO, Nelson DA, Merlin MA.
Resuscitation. 2010 Jan;81(1):42-6. Epub 2009 Nov 13.
PMID: 19913979 [PubMed – indexed for MEDLINE]

[2] Antiarrhythmics
2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science
Part 8: Adult Advanced Cardiovascular Life Support
Part 8.2: Management of Cardiac Arrest
Medications for Arrest Rhythms
Free Full Text from Circulation with link to PDF Download

[3] What About IV Epinephrine for Patients Who Are Not Dead
Rogue Medic
Fri, 30 Mar 2012
Article

Saybolt, M., Alter, S., Dos Santos, F., Calello, D., Rynn, K., Nelson, D., & Merlin, M. (2010). Naloxone in cardiac arrest with suspected opioid overdoses Resuscitation, 81 (1), 42-46 DOI: 10.1016/j.resuscitation.2009.09.016

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What About Nebulized Naloxone (Narcan) – Part II


This is continuing from Part I about a recent paper looking at the use of nebulized naloxone (Narcan) to treat possible opioid OD (OverDose).

What are the indications for naloxone?

To diagnose heroin OD?

 

Absolutely not!

 

If we are that bad at assessment, that we need naloxone to identify a heroin OD, then we are not good enough at assessment to be treating patients with any medications.

The protocol-specified nebulization of 2 mg of naloxone with 3 mL of normal saline as empiric treatment for suspected opioid overdose or undifferentiated depressed respirations as long as the patient had some spontaneous respiratory effort, no apnea, and no severe cardiorespiratory compromise (shock, impending respiratory arrest).[1]

In other words, patients who probably will not receive much benefit from naloxone.

Excluded from analysis were cases where nebulized naloxone was given for opioid-triggered asthma and cases with incomplete outcome data.[1]

The omission of the patients (only 3 patients) with incomplete outcome data is legitimate, but not enough data is presented in the paper.

The omission of the asthma patients (21 patients) is interesting. Why not break them out into a different group and analyze with the asthmatics, without the asthmatics, and just the asthmatics? We are trying to find out what works and if it is safe, aren’t we?

Secondary outcomes included need for rescue naloxone (IV or IM), need for assisted ventilation by bag–valve–mask (BVM) assistance or intubation, and adverse antidote events (respiratory arrest, cardiac arrest, death in the field).[1]

The word need is used rather casually. How do they define need?

Why are rescue naloxone, BVM assistance, and intubation not considered adverse antidote events, while respiratory arrest, cardiac arrest, and death are considered adverse antidote events? I do not see the distinction.

I don’t think that naloxone-induced respiratory arrest is going to catch on as a diagnosis. Maybe they are referring to patients who did not receive enough naloxone, due to respirations that are too shallow?

We found that nebulized naloxone is a safe and effective needleless antidote for prehospital treatment of suspected opioid overdose in patients with spontaneous respirations. Eighty percent of the patients treated had some response to treatment, and only 10% of the patients were given a second dose of naloxone. No patient required intubation or BVM-assisted ventilation.[1]

Why were partial responders not given more naloxone?

Why were any of these patients given naloxone?

In our study, no patient signed out against medical advice and all patients were transported to the hospital.11 [1]

22% had complete response to the nebulized naloxone. 5% had complete response to the rescue naloxone.

Nobody refused treatment of transport?

How complete was the response?

Do the police threaten to arrest the patients unless they agree to transport? Why do all of the patients complete the transport?

The literature on intranasal naloxone exemplifies this problem, thus the GCS, respiratory rate (RR), and paramedic impression have been used as outcome measures by others as well.4 – 7 [1]

What about skin color and temperature?

What about pulse oximetry and waveform capnography? These are objective.

Maybe the outcome measures depend on the original indication for naloxone.

Is GCS (Glasgow Coma Score) important?

Not really.

The patient is not going to die of a depressed GCS. Depressed/absent respirations are a different story.

Finally, we did not compare nebulized naloxone with IV naloxone, the recognized “gold standard,” nor were we able to confirm opioid overdose through hospital records.[1]

Gold Standard?

For what?

The goal of treatment is a patient able to protect his own airway and breathing adequately, regardless of whether the patient has ever received any naloxone. Giving naloxone to a patient who meets these criteria is not good medicine.

To be continued in Part III.

Footnotes:

[1] Can Nebulized Naloxone Be Used Safely and Effectively by Emergency Medical Services for Suspected Opioid Overdose?
Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB.
Prehosp Emerg Care. 2011 Dec 22. [Epub ahead of print]
PMID: 22191727 [PubMed – as supplied by publisher]

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What About Nebulized Naloxone (Narcan) – Part I

There is a recent paper looking at the use of nebulized naloxone (Narcan) to treat possible opioid OD (OverDose), or something like that. It is not exactly clear what is being treated. First, we probably want to minimize the use of IV/IM needles when dealing with a population that is not expected to be good at preventing transmission of bloodborne pathogens, even where needle exchange programs decrease that risk.
 


Image credit.
 

Needleless naloxone may be easier when intravenous (IV) access is difficult and may decrease occupational blood-borne exposure in this high-risk population. Several studies have examined intranasal naloxone, but nebulized naloxone as an alternative needleless route has not been examined in the prehospital setting.[1]

It is a good idea to compare the two treatments and to include placebo versions of both. If only one route/treatment is being used, to at least compare that route/treatment with placebo. This is the way that we learn what works, but that is not the way this study was run.

The second reason this makes for a poor outcome measure is that the medics are not “blinded” to the treatment the patient got – they all knew they were giving an active agent.[2]

Without anything to compare the treatment with, we are only determining if the result is acceptable.

What does acceptable mean in this study?

Did the naloxone improve the any patient’s respiratory rate?

Did the naloxone improve the any patient’s pulse oximetry?

Did the naloxone improve the any patient’s heart rate (bradycardia is a common side effect of opioid-induced respiratory depression)?

Or did the naloxone just appear to improve the level of consciousness of some patients?

Why should we be giving naloxone?

The documented indication for nebulized naloxone administration was suspected opioid overdose in 70 patients (66.7%), altered mental status in 34 patients (32.3%), and respiratory depression in one patient (0.9%).[1]

 

Why?

 

Suspected opioid OD (not just any OD and it depends on what else is on board) with respiratory depression.

Without respiratory depression, there is no need for naloxone, unless it is to get the patient to walk to the ambulance. If that is the reason, does the patient really need to be transported to the hospital?

Is that really better than giving the Goldolocks amount of naloxone to allow the patient to safely refuse further treatment? The concern is the respiratory depression/inability to protect the airway.

Aren’t we checking for a gag reflex?

Not me. Where is the benefit in that?

If the patient is not breathing adequately, is there any expectation that giving a nebulized reversal agent will effectively treat the respiratory depression? That is the question that should have been asked. I think that there is a good reason to expect nebulized naloxone to work with significant respiratory depression and that it may be safe and effective, but I think that we definitely need to demonstrate this in a study that documents the changes in vital signs, so that we can identify potential problems early.

To be continued in Part II and Part III.

Footnotes:

[1] Can Nebulized Naloxone Be Used Safely and Effectively by Emergency Medical Services for Suspected Opioid Overdose?
Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB.
Prehosp Emerg Care. 2011 Dec 22. [Epub ahead of print]
PMID: 22191727 [PubMed – as supplied by publisher]

[2] Narcan Nebs – Why? New research doesn’t say..
Sunday, January 22, 2012
Mill Hill Ave Command
Article

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Happy Excited Delirium


What a Trip! is a post over at EMS Outside Agitator. firetender discusses a video of Excited Delirium Syndrome (ExDS). Some people may think that this patient does not have excited delirium, because the patient is so cooperative. That is a mistake.

If EMS had this patient on the monitor, there would be a lot of artifact, but we should expect to see a very elevated heart rate. Probably over 120 beats per minute. The patient is not trying to harm anyone else, but his body is working so hard that he can be hurting himself. He is a danger to himself. If over 8% (one out of every dozen) of these patients die from excited delirium, he will probably not die.

Wait – looking at those numbers is misleading without putting the numbers in context.

The majority of lethal ExDS patients die shortly after a violent struggle. Severe acidosis appears to play a prominent role in lethal ExDS-associated cardiovascular collapse.[1]

We also do not know how much sedation will affect the outcome. We need some sort of studies comparing the outcomes of excited delirium patients who are not sedated with the outcomes of excited delirium patients who are sedated.

While regular exercise is protective and youthful bodies can withstand more punishment, extreme stress can kill, and stress is most extreme near the end of a race.[2]

When the person is restrained, there is no end of the race. It is just fight against the restraints until there is no fight left.

The patient is vigorously struggling against the straps, even though he did cooperate and lie down when the officer asked him to. Just because he is not trying to hurt anyone does not mean that he is not struggling. This is a form of extreme exertion.

If you want to know what this is like, have someone strap you to a board. Then have them inject you with a large dose of epinephrine. Then you can try to get out by breaking the straps. Maybe you will not try very hard, but if you do put a lot of effort into this, you will quickly exhaust yourself. Maybe you will kill yourself. This is extreme exertion and the people involved are usually not in excellent physical shape.

I am just kidding about the epinephrine. While it would be one way to experience what the patients are experiencing, it is a really bad idea. Epinephrine might as well be a heart attack in a syringe.

Maybe this is the rhythm –

Maybe this is the rhythm –

Maybe it is some other rhythm.

We don’t know.

We can’t tell.

firetender has a video on his post, but there is a better video here. Unfortunately, I cannot embed it. This starts with the call to dispatch, then switches to video from the scene.

At 4:15 (of the linked video) the officer to tell the ambulance, I believe we have an excited delirium case. This is excellent communication and the right assessment.

What should EMS do for excited delirium?

Sedation.

What if that doesn’t work?

More sedation.

What if that doesn’t work?

Even more sedation until it does work or we run out of sedation.

At 5:37 (of the linked video) someone mentions, We’ve got Narcan and Haldol, or he said We gave Narcan and Haldol. I did not hear any other mention of EMS medications at any point, but the narrators drown out a lot of what is said.

Naloxone (Narcan) will only make this patient worse. If I run out of sedative, I want to give him morphine or fentanyl until he is sedated or until I run out of sedating medication to give. Opioids do have a sedating effect. Naloxone is for respiratory depression – where is there any sign of respiratory depression?[3] If we give naloxone to these patients, we may kill them.

Was naloxone given or just mentioned?

I don’t know, but if naloxone was given, too much was given.

Was haloperidol (Haldol) given or just mentioned?

I don’t know, but if haloperidol was given, not enough was given.

Here is a different example of excited delirium. This one was fatal. The patient was not attacking any of the police, he was only trying to keep from being restrained.


Download YouTube Video | YouTube to MP3: Vixy | Replay Media Catcher

The treatment is sedation. Unfortunately, restraints generally need to be used to get the patient in a position where it is safe to give medication. A Taser is another way to stop the patient for long enough to get a lot of sedative into the patient.

Small doses kill, because they usually don’t even slow the patient down and may make the patient even more agitated. Yes, that is possible.

Excited delirium is a psychological and metabolic emergency. The metabolic emergency is what kills patients. This is not the time to try to get patients to tough it out the all-natural way.

Footnotes:

[1] White Paper Report on Excited Delirium Syndrome
ACEP Excited Delirium Task Force
Vilke GM, Debard ML, Chan TC, Ho JD, Dawes DM, Hall C, Curtis MD, Costello MW, Mash DC, Coffman SR, McMullen MJ, Metzger JC, Roberts JR, Sztajnkrcer MD, Henderson SO, Adler J, Czarnecki F, Heck J, Bozeman WP.
September 10, 2009
Free Full Text PDF

[2] Philly Runners’ Deaths Point to Dangers of Extreme Stress on the Body – Between 6% & 17% of sudden cardiac deaths are associated with exertion
JEMS.com
Kia Gregory and Don Sapatkin
The Philadelphia Inquirer
Tuesday, November 22, 2011
Article

[3] Scopolamine Poisoning among Heroin Users — New York City, Newark, Philadelphia, and Baltimore, 1995 and 1996
MMWR (Morbidity and Mortality Weekly Report).
Vol 45, No 22;457;
Free Full Text . . . . Free PDF

On March 16, 1995, eight persons were treated in the emergency department (ED) of a Bronx hospital for acute onset of agitation and hallucinations approximately 1 hour after “snorting” heroin. On physical examination, all these persons had clinical manifestations of anticholinergic toxicity (i.e., tachycardia, mild hypertension, dilated pupils, dry skin and mucous membranes, and diminished or absent bowel sounds); five had urinary retention. All were initially lethargic and became agitated and combative after emergency medical service (EMS) personnel treated them with parenteral naloxone, which is routinely used for suspected heroin overdose to reverse the toxic effects of opioids (e.g., coma and respiratory depression). All patients received diazepam or lorazepam for sedation, and signs and symptoms resolved during the next 12-24 hours.

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