Suboxone Overdose and Treatment

[Samtansey]

23-year-old male with history of polysubstance abuse, particularly benzodiazepines, heroin and cocaine. Mother brought patient into the ED and patient collapsed in ED waiting room. He was administered 2mg IVP Narcan x2 which made him arouse. Patient was in ED room where he was being monitored by security, he asked to use the commode where the security gave him privacy. During this moment of privacy, he pulled out a balloon from his rectum which he admitted to being "2 bundles of suboxone" which he snorted and then proceeded to get back into bed (after stealing a bunch of IV start kits from the nearby cart). Patient was found nonresponsive again and hypoxic with an O2 saturation in the 70s. He was manually bagged, given IVP Narcan x2, before being started on a Narcan gtt. Patient was then placed on a NRB before I came down to bring him up to ICU. His VSS on NRB, but only responsive to painful stimuli.

Labs:
Urine positive for Cocaine and benzodiazepines.
Urine negative for opiods
BAC 0.03
Lactate 1.7
ABG (after being on NRB for 30 minutes): pH 7.37, PCO2: 57, PO2 >500, HCO3 27

On arrival to the ICU, he remained only responsive to painful stimuli for 6hours. He remained on the Narcan gtt with NS at 125mL/hr. The Narcan gtt is titratable but it had already been titrated up so high that I clarified with the MD if he wanted me to continue to titrate up. MD declined, said to keep the Narcan gtt at its current rate, and that he did not want to pursue any further action or administer anything. I verified that he aware of patient urine being positive for cocaine and benzos, and that MD acknowledged and clarified that he wanted no further action for this patient.

After reviewing ABG, patient was changed over to 3 L via NC, and VS remained stable for the rest of the night. Patient placed on CIWA protocol (though nothing ordered PRN) for which patient didn't score.

When patient aroused, he was drowsy but could recall the events of the night. He started that the previous day he took "benzos, 2 tabs of acid, suboxone" and then "2 bundles of suboxone" when he was left alone with the commode. He began stating that he needed subozone and benzodiazepines to function due to his history of anxiety disorder and agoraphobia, and he takes it everyday. He began trying to take out his IVs and wanted to go home, however he made him aware that he couldn't leave for the sake of his safety for which the patient reluctantly agreed. MD discontinued Narcan gtt and wanted to order no further action.


My question: Was this handled correctly? I'm normally in the CCU, so this whole thing is new to me.

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[WilcoWorld]

Sounds like your team saved his life.

 

[Zebra Hunter]

Do you have any specific issues with the management? Because it sounds like you're fishing for a specific response to this.

 

[da8s0859q]

Do you have any specific issues with the management? Because it sounds like you're fishing for a specific response to this.

My feeling as well.

 

[goodoldalky]

Do you have any specific issues with the management? Because it sounds like you're fishing for a specific response to this.

Oh, oh, I know! Ask us if they should have given flumazenil!!

 

[engineeredout]

Sounds like you wanted the narcan gtt titrated up higher so that the patient was wide awake, talking, and eating, without understanding that the only titration of narcan should be to allow for an appropriate respiratory drive, nothing more, nothing less

 

[DocEspana]

So I live in the Capitol of methadonia. Suboxone is a rarity in my community. Everyone prefers the zombie inducing methadone. So my experience with it is quite limited. But every time (minus one or two random tourisrs wandering into the hood) I see it, it's from an attempted overdose. The conversations go like this.

Me: why are you here?
Pt: I tried to kill myself/get high with <insert comical amount> if Suboxone
Me: and how do you feel right now
Pt: like.... just a little high
Me: yeah. That's how it works.
Pt: shouldn't I be like.... dying?
Me: No. You're just more poor than you were before you bought all that Suboxone

And then they just sit there wide awake for a few hours needlessly as they never show any symptoms. My (admittedly somewhat limited) clinical experience and the activity curves of Suboxone suggest (to me at least) you'd need polypharmacy to ever get in a situation like this, and likely non-opiate polypharmacy.

Are people really seeing Suboxone overdoses?

 

[WilcoWorld]

So I live in the Capitol of methadonia. Suboxone is a rarity in my community. Everyone prefers the zombie inducing methadone. So my experience with it is quite limited. But every time (minus one or two random tourisrs wandering into the hood) I see it, it's from an attempted overdose. The conversations go like this.

Me: why are you here?
Pt: I tried to kill myself/get high with <insert comical amount> if Suboxone
Me: and how do you feel right now
Pt: like.... just a little high
Me: yeah. That's how it works.
Pt: shouldn't I be like.... dying?
Me: No. You're just more poor than you were before you bought all that Suboxone

And then they just sit there wide awake for a few hours needlessly as they never show any symptoms. My (admittedly somewhat limited) clinical experience and the activity curves of Suboxone suggest (to me at least) you'd need polypharmacy to ever get in a situation like this, and likely non-opiate polypharmacy.

Are people really seeing Suboxone overdoses?

Makes sense, it's got to be hard to overdose on opiates when the drug your taking contains naloxone.

 

[TooMuchResearch]

Management seems fine.

 

[Samtansey]

Oh, oh, I know! Ask us if they should have given flumazenil!!

Thank you for your enthusiasm. Well he was a benzo addict, so I assumed that's why they did not give flumazenil. I just never had an OD before, and I was unsure if it was appropriate that he had a GCS of 3 for most of my shift. Whether I should have done more, or if I should have expected some further treatment/testing/etc.

 

[Samtansey]

Sounds like you wanted the narcan gtt titrated up higher so that the patient was wide awake, talking, and eating, without understanding that the only titration of narcan should be to allow for an appropriate respiratory drive, nothing more, nothing less

My hospital protocol made it seem as though I was supposed to titrate upwards for responsiveness rather than respiratory drive. So that makes more sense.

 

[Samtansey]

Do you have any specific issues with the management? Because it sounds like you're fishing for a specific response to this.

Well I'm specifically fishing for if anything else should have been done. If not, great. Again, this whole situation was new to me and letting my patient be for the most part nonresponsive for the bulk of his time following what happened made me a little uncomfortable. However, if that's an expected outcome and not necessarily a cause for concern, then okay.

 

[Apollyon]

Well I'm specifically fishing for if anything else should have been done. If not, great. Again, this whole situation was new to me and letting my patient be for the most part nonresponsive for the bulk of his time following what happened made me a little uncomfortable. However, if that's an expected outcome and not necessarily a cause for concern, then okay.

Well, you get points for, first, coming back. Then, you're clear and open and gracious - which, for me to remark on that, implies that most are not that, or do not do that.

That said, bring unresponsive is not the "expected outcome"; look at it from the other side. Dude is breathing, with Narcan titrated to respiration. Go from there. If you look at being alive as a whole bunch of autonomic functions, with consciousness being a cherry on top, then your perspective changes.

 

[shoal007]

we do this all the time in the ED. drug, etoh etc. it takes some balls but its the right thing. they usually do fine. sometimes you find something else out (ohhh ohh SAH, etoh is 0). but this case you have a clear baseline without trauma. handled perfectly.

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[BoardingDoc]

Well I'm specifically fishing for if anything else should have been done. If not, great. Again, this whole situation was new to me and letting my patient be for the most part nonresponsive for the bulk of his time following what happened made me a little uncomfortable. However, if that's an expected outcome and not necessarily a cause for concern, then okay.

That is the expected outcome. Narcan is great at getting people to breathe, it's not great at making them pleasant.

If you give someone just enough narcan to keep them breathing, then by the time they start talking to you you can be fairly confident that most of the drugs are out of their system and they'll be ok when you turn the narcan off.

If you give them enough to wake up, you frequently push them straight into withdrawal and they start screaming, being an dingus and demanding to leave. The problem is, the drugs last longer than the narcan, so you turn off the drip, they stay conscious long enough to leave and then they drop again once they're gone (or they drop while waiting to leave and you start all over).

The only time I ever want to give someone narcan and have them wake up as a result is if they are coding/peri-code.

 

[Druggernaut]

Thank you for your enthusiasm. Well he was a benzo addict, so I assumed that's why they did not give flumazenil. I just never had an OD before, and I was unsure if it was appropriate that he had a GCS of 3 for most of my shift. Whether I should have done more, or if I should have expected some further treatment/testing/etc.

Without seeing the patient, I'd say I would have escalated to either some push doses of Narcan or just intubated him and shut off the infusion if he truly had a GCS of 3. But you noted earlier that he was responsive to painful stimuli, so I'm assuming that GCS of 3 is hyperbole. It sounds like he came out of it okay in the end without plastic through his cords, so they made the right call.

If you give someone just enough narcan to keep them breathing, then by the time they start talking to you you can be fairly confident that most of the drugs are out of their system and they'll be ok when you turn the narcan off.

If you give them enough to wake up, you frequently push them straight into withdrawal and they start screaming, being an dingus and demanding to leave. The problem is, the drugs last longer than the narcan, so you turn off the drip, they stay conscious long enough to leave and then they drop again once they're gone (or they drop while waiting to leave and you start all over).

Side note, but how long are people here typically watching people after giving Narcan? I typically shoot for about two if they've been reversed to an essentially normal mental status, but some sources suggest longer.

 

[Samtansey]

Without seeing the patient, I'd say I would have escalated to either some push doses of Narcan or just intubated him and shut off the infusion if he truly had a GCS of 3. But you noted earlier that he was responsive to painful stimuli, so I'm assuming that GCS of 3 is hyperbole. It sounds like he came out of it okay in the end without plastic through his cords, so they made the right call.

Thank you for pointing that out. I personally couldn't get him to arouse with sternal rub, however the much stronger RT and intensivist did assure me that they could. So based soley on my own assessment, I would have described his GCS as a 3. I used the MD's description of events for my original post, so sorry for the contradiction. Thank you for your input on how you would handle the situation though.

 

[Samtansey]

Well, you get points for, first, coming back. Then, you're clear and open and gracious - which, for me to remark on that, implies that most are not that, or do not do that.

That said, bring unresponsive is not the "expected outcome"; look at it from the other side. Dude is breathing, with Narcan titrated to respiration. Go from there. If you look at being alive as a whole bunch of autonomic functions, with consciousness being a cherry on top, then your perspective changes.

Thank you very much for your kind words, and your very helpful description.

 

[Samtansey]

That is the expected outcome. Narcan is great at getting people to breathe, it's not great at making them pleasant.

If you give someone just enough narcan to keep them breathing, then by the time they start talking to you you can be fairly confident that most of the drugs are out of their system and they'll be ok when you turn the narcan off.

If you give them enough to wake up, you frequently push them straight into withdrawal and they start screaming, being an dingus and demanding to leave. The problem is, the drugs last longer than the narcan, so you turn off the drip, they stay conscious long enough to leave and then they drop again once they're gone (or they drop while waiting to leave and you start all over).

The only time I ever want to give someone narcan and have them wake up as a result is if they are coding/peri-code.

That was very helpful, thank you very much!

 

[engineeredout]

Side note, but how long are people here typically watching people after giving Narcan? I typically shoot for about two if they've been reversed to an essentially normal mental status, but some sources suggest longer.

Depends. Heroin? 2 hours usually fine if they're completely awake/alert. PO opioids? Likely for longer as they slow GI motility so longer absorption, and there's many extended release formulations (frequently end up OBSing methadone ODs). Plus with PO you may end up needing at least four hour postingestion Tylenol levels and possibly repeat ones depending on your practice and what literature you read

 

[gutonc]

I would think that most ICU/floor RNs would say that a patient who's breathing on his own with stable vitals and not doing anything else all shift is the perfect one to have.

 

[DocEspana]

Side note, but how long are people here typically watching people after giving Narcan? I typically shoot for about two if they've been reversed to an essentially normal mental status, but some sources suggest longer.

So we just did a literature review of this on one of my offservice rotation and it was noted that studies attempting to identify if "narcan and release" is appropriate for undifferentiated opiate toxicity show that our concerns about relapsing into a dangerous state are nearly entirely without any merit.

I am NOT suggesting to take thst data (a few studies with robust n values, but all with the issues of difficulty assuring the patient didn't disappear and die somewhere outside of the hospitals grasp to catch it) and run with it. It sort of flies in the face of what we assume to be physiology. But the general feeling is that the super dangerous hypoxic nadir may actually be quite brief and if they're awake for it, or still trying to metabolize some of the remaining narcan, they just won't go back to that dangerous spot.

With that said, I try to keep them 90 minutes to 2 hours before I say they can go. But it was noted that a room full of 26 ER doctors at various levels of training from multiple institutions had seen exactly zero situations where they had to give narcan a second time for return of dangerous hypoventilation. It was brought up that nearly all of the narcan drip literature comes icu settings where they have different acceptable thresholds for ventilation and also have different (iatrogenic) causes while nearly no data for drips comes from the ER end, though we do use it based on the icu literature.

 

[WildcatS11]

That is the expected outcome. Narcan is great at getting people to breathe, it's not great at making them pleasant.

If you give someone just enough narcan to keep them breathing, then by the time they start talking to you you can be fairly confident that most of the drugs are out of their system and they'll be ok when you turn the narcan off.

If you give them enough to wake up, you frequently push them straight into withdrawal and they start screaming, being an dingus and demanding to leave. The problem is, the drugs last longer than the narcan, so you turn off the drip, they stay conscious long enough to leave and then they drop again once they're gone (or they drop while waiting to leave and you start all over).

The only time I ever want to give someone narcan and have them wake up as a result is if they are coding/peri-code.

This is a pet peeve of mine. If someone is legitamitely arresting because of a heroin overdose, it is NOT because of the opiate induced hypoventilation - it is the resultant hypoxia causing PEA.

If someone is in PEA from hypoxia from ANY cause - what do you expect to happen with narcan administration? Reversing the narcotic will not start their heart again. They need a source of oxygen and ventilation.

I find the "code dose" of narcan kind of silly for this reason. If someone has already arrested, they are beyond the reach of naloxone.

 

[Rendar5]

Makes sense, it's got to be hard to overdose on opiates when the drug your taking contains naloxone.

It's not the Naloxone that is responsible for this.
Naloxone cannot be absorbed by the gi tract. The reason why it's hard to overdose on Suboxone is because buprenorphine is a partial agonist. The naloxone is just there to prevent people from injecting it which would put them into withdrawal if they were dependent.

 

[WilcoWorld]

The naloxone is just there to prevent people from injecting it which would put them into withdrawal if they were dependent.

Thanks for the additional detail - that is an important point about buprenorphine that I did not cover in my (admittedly off-the-cuff) earlier post. However, it doesn't make the quoted portion of your post a non-issue. After all, if that were the case, then why include the naloxone at all? Just to prophylax against opioid-induced constipation?

 

[umt43]

Like the person above you said, it's to prevent abuse. If you take the suboxone by mouth (as you're supposed to), all you get is the desired effect of the buprenorphine, as none of the naloxone is absorbed by the GI tract. However, try to abuse it by injecting it and you get a whopping dose of the now physiologically active naloxone. Sure, you can down a whole bunch of oral pills and get more of the narcotic effect, but it prevents a person from injecting it to get that immediate high.

 

[WilcoWorld]

The pharmacology of Suboxone is full of a lot of cool things, and I genuinely appreciate the discussion as it highlights some useful EM knowledge, not just esoterica- such as the fact that oral naloxone can be used to treat opiate-induced constipation without precipitating withdrawal, because naloxone is poorly absorbed from the GI track.

However, I'm concerned that some seem to think it's impossible to overdose on Suboxone. It's not impossible, it's just much much harder than it is to OD on other opiates & opioids.

If you don't believe me, read the OP's personal report of someone needing a narcan drip and an ICU stay after snorting Suboxone (I know, you can't always trust the patient, and this could definitely been a mixed ingestion).
Well, in this report published in JAMA some deaths were attributed to buprenorphine. Admittedly, this is not entirely convincing, given the methods would allow for significant polypharmacy to be contributing.
So then consider this case series of unintentional pediatric exposures. Seems less likely that toddlers would have co-ingestions.

 

[WheezyBaby]

If suboxone is causing overdoses, I'd expect it'd be predominantly in opioid naive patients, where the partial agonism is still far more opioid activity than their bodies are accustomed to

 

[TooMuchResearch]

Without seeing the patient, I'd say I would have escalated to either some push doses of Narcan or just intubated him and shut off the infusion if he truly had a GCS of 3. But you noted earlier that he was responsive to painful stimuli, so I'm assuming that GCS of 3 is hyperbole. It sounds like he came out of it okay in the end without plastic through his cords, so they made the right call.



Side note, but how long are people here typically watching people after giving Narcan? I typically shoot for about two if they've been reversed to an essentially normal mental status, but some sources suggest longer.

Our poison/tox folks are recommending 4-6 hours now. Too many fentanyl-type drugs and other junk on the market.

If the hospital has space, I obs some of them. 4-6 hours is a long time to watch downstairs.

 

[TooMuchResearch]

So we just did a literature review of this on one of my offservice rotation and it was noted that studies attempting to identify if "narcan and release" is appropriate for undifferentiated opiate toxicity show that our concerns about relapsing into a dangerous state are nearly entirely without any merit.

I am NOT suggesting to take thst data (a few studies with robust n values, but all with the issues of difficulty assuring the patient didn't disappear and die somewhere outside of the hospitals grasp to catch it) and run with it. It sort of flies in the face of what we assume to be physiology. But the general feeling is that the super dangerous hypoxic nadir may actually be quite brief and if they're awake for it, or still trying to metabolize some of the remaining narcan, they just won't go back to that dangerous spot.

With that said, I try to keep them 90 minutes to 2 hours before I say they can go. But it was noted that a room full of 26 ER doctors at various levels of training from multiple institutions had seen exactly zero situations where they had to give narcan a second time for return of dangerous hypoventilation. It was brought up that nearly all of the narcan drip literature comes icu settings where they have different acceptable thresholds for ventilation and also have different (iatrogenic) causes while nearly no data for drips comes from the ER end, though we do use it based on the icu literature.

We're seeing quite a few that need repeat Narcan for hypoventilation. Even the "heroin" overdoses.

 

[DocEspana]

We're seeing quite a few that need repeat Narcan for hypoventilation. Even the "heroin" overdoses.

My suggestion would be to publish it. Not joking. We all "know" it and as such we assume it's in the literature. It's not. The literature is pretty monolithic that people don't actually re-enter dangerous opiate rebound, or if they do they are managing to make it outside of county/state lines before re-entering such a state. But in thjs case "monolithic" is only about 4 quality studies (we did reject case reports or poorly designed analysis) so it's barely any evidence at all in the big picture. If it's the case that relapse happens, and I imagine it might be, it should be out there in the data much more than it is.

 

[chrystal0120]

Once had a pt come in profoundly diaphoretic, huge pupils and vomiting and diarrhea simultaneously. Both ends continuous. He was screaming Narc withdrawal but stated he just shot up 40mg oxy. He finally showed us one of the pills. Turns out it was actually Targiniq (oxycodone/naloxone combo - idea being if taken orally it would help decrease the constipating etc. side effects of the oxy).


Sadly this poor chap had ended up giving himself 40mg IV oxy but also 20mg IV naloxone.
I've never seen one young adult male covered in so much of his own bodily fluids
He put in a few hard hours. Doubt it deterred him from shooting up next time though.....


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[da8s0859q]

Once had a pt come in profoundly diaphoretic, huge pupils and vomiting and diarrhea simultaneously. Both ends continuous. He was screaming Narc withdrawal but stated he just shot up 40mg oxy. He finally showed us one of the pills. Turns out it was actually Targiniq (oxycodone/naloxone combo - idea being if taken orally it would help decrease the constipating etc. side effects of the oxy).


Sadly this poor chap had ended up giving himself 40mg IV oxy but also 20mg IV naloxone.
I've never seen one young adult male covered in so much of his own bodily fluids
He put in a few hard hours. Doubt it deterred him from shooting up next time though.....


Sent from my iPhone using SDN mobile

You joined in 2009, and this is your first post! Well done.

 

[Zebra Hunter]

Our poison/tox folks are recommending 4-6 hours now. Too many fentanyl-type drugs and other junk on the market.

If the hospital has space, I obs some of them. 4-6 hours is a long time to watch downstairs.

That recommendation from your tox folks makes absolutely no sense. The typical obs time for opiate OD following narcan administration is 1.5-2hrs not because of the duration of action of heroin, but the duration of action of narcan. Narcan lasts up to 90 minutes, but usually is less than that. If the patient is still a&ox4 after 2 hours, it means the opiate has likely been mostly metabolized, and there is no reason to obs any longer.

 

[Zebra Hunter]

This is a pet peeve of mine. If someone is legitamitely arresting because of a heroin overdose, it is NOT because of the opiate induced hypoventilation - it is the resultant hypoxia causing PEA.

If someone is in PEA from hypoxia from ANY cause - what do you expect to happen with narcan administration? Reversing the narcotic will not start their heart again. They need a source of oxygen and ventilation.

I find the "code dose" of narcan kind of silly for this reason. If someone has already arrested, they are beyond the reach of naloxone.

I'm confused on what your issue is with narcan in a opiate intoxication code. I doubt the person you quoted is just starting an IV/IO, pushing narcan and stepping back and saying "Welp, hopefully this works". Chest compressions, BVM, and narcan cures most of these patients, as long as they were not down too long. Most come around within seconds after narcan administration. Reversing the narcotic actually will indirectly start their heart again by getting the patient to spontaneously breath. There is one of these every other shift where I'm at. Also, I think people seem to forget that PEA arrest does not always mean that there is no cardiac output.

 

[WildcatS11]

I'm confused on what your issue is with narcan in a opiate intoxication code. I doubt the person you quoted is just starting an IV/IO, pushing narcan and stepping back and saying "Welp, hopefully this works". Chest compressions, BVM, and narcan cures most of these patients, as long as they were not down too long. Most come around within seconds after narcan administration. Reversing the narcotic actually will indirectly start their heart again by getting the patient to spontaneously breath. There is one of these every other shift where I'm at. Also, I think people seem to forget that PEA arrest does not always mean that there is no cardiac output.

I don't really think so. Definitely "pericode" it is useful, but a heroin OD who has arrested is not going to just "wake up" with narcan. They need oxygen and ventilation. If they've gotten to that point, narcan will not provide either of those things.

I understand nobody is "just giving narcan." My point is - it is the other things that help - BVM or invasive ventilation. The narcan is a waste of time at that point. If you have given a coding patient narcan alone and seen them wake up in front of your eyes - please enlighten me.

 

[Zebra Hunter]

I don't really think so. Definitely "pericode" it is useful, but a heroin OD who has arrested is not going to just "wake up" with narcan. They need oxygen and ventilation. If they've gotten to that point, narcan will not provide either of those things.

I understand nobody is "just giving narcan." My point is - it is the other things that help - BVM or invasive ventilation. The narcan is a waste of time at that point. If you have given a coding patient narcan alone and seen them wake up in front of your eyes - please enlighten me.

If you believe that, then you have not seen enough of these patients. The harms of intubation are a lot more common than the harms of narcan. Just give them the dang antidote. Start resuscitation, give narcan, if it doesn't work, tube them. No harm done. Stop over-thinking it. I've seen 1 heroin code that responded to narcan immediately, with the patient only on a nasal cannula (I walked in on this and had no clue why no one was ventilating the pt), but compressions had already been started. I've seen 1 heroin code where RT was bagging the patient and obviously had no seal with the mask, when narcan was administered and that patient woke up enough to cuss everyone out for cutting off his shirt. I had 1 last week where the patient's "friend" dropped her on the floor of the waiting room and compressions, IV placement and narcan had already been started by the time the ambubag had been taken out, and that patient immediately responded, as well. You obviously should not be doing narcan alone, but it can save someone that is technically coding because like I said before, PEA does not always equal no cardiac output, and if you have some CO, it means you will have narcan infused blood reaching the respiratory centers of the brainstem which can lead to spontaneous respirations.

I really hope you aren't forgoing narcan in these situations just because in your opinion, it might not be helpful. You can save a lot of these patients from unnecessary intubations and hospital stays where they rack up healthcare costs, take up ICU beds, get ventilator associated PNAs, etc.

 

[WilcoWorld]

PEA does not always equal no cardiac output

I agree with your argument, and I think that this is the key point right here.

Not being able to find a pulse during a code =/= zero cardiac output. Add to that the fact that naloxone has some vasopressor activity, and your stories of Narcan-->Lazarus make a lot of physiologic sense.

Of course, Zerbra Hunter is not arguing that we should withhold ventilation or compressions during a code. Likewise, I hope WildcatS11 is not actually advocating for withholding naloxone during opiate-related codes, but rather stressing the point that attention should be focused on restoring ventilation, as these are primary respiratory arrests.

I wonder if a lot of the arguments like this that we get into on this forum stem from our boards preparation where we're forced to choose "the most appropriate initial action". In real life, I never do just one thing. In a real code, my team and I are doing about a half a dozen things in parallel (narcan, compressions, ventilation, getting the patient on the monitor, pulling up the latest discharge sumarry, getting additional IV access, etc).

 

[alpinism]

This is a pet peeve of mine. If someone is legitamitely arresting because of a heroin overdose, it is NOT because of the opiate induced hypoventilation - it is the resultant hypoxia causing PEA.

If someone is in PEA from hypoxia from ANY cause - what do you expect to happen with narcan administration? Reversing the narcotic will not start their heart again. They need a source of oxygen and ventilation.

I find the "code dose" of narcan kind of silly for this reason. If someone has already arrested, they are beyond the reach of naloxone.

Also a huge pet peeve and completely agree.

If you believe that, then you have not seen enough of these patients. The harms of intubation are a lot more common than the harms of narcan. Just give them the dang antidote. Start resuscitation, give narcan, if it doesn't work, tube them. No harm done. Stop over-thinking it. I've seen 1 heroin code that responded to narcan immediately, with the patient only on a nasal cannula (I walked in on this and had no clue why no one was ventilating the pt), but compressions had already been started. I've seen 1 heroin code where RT was bagging the patient and obviously had no seal with the mask, when narcan was administered and that patient woke up enough to cuss everyone out for cutting off his shirt. I had 1 last week where the patient's "friend" dropped her on the floor of the waiting room and compressions, IV placement and narcan had already been started by the time the ambubag had been taken out, and that patient immediately responded, as well. You obviously should not be doing narcan alone, but it can save someone that is technically coding because like I said before, PEA does not always equal no cardiac output, and if you have some CO, it means you will have narcan infused blood reaching the respiratory centers of the brainstem which can lead to spontaneous respirations.

I really hope you aren't forgoing narcan in these situations just because in your opinion, it might not be helpful. You can save a lot of these patients from unnecessary intubations and hospital stays where they rack up healthcare costs, take up ICU beds, get ventilator associated PNAs, etc.

I agree with your argument, and I think that this is the key point right here.

Not being able to find a pulse during a code =/= zero cardiac output. Add to that the fact that naloxone has some vasopressor activity, and your stories of Narcan-->Lazarus make a lot of physiologic sense.

Of course, Zerbra Hunter is not arguing that we should withhold ventilation or compressions during a code. Likewise, I hope WildcatS11 is not actually advocating for withholding naloxone during opiate-related codes, but rather stressing the point that attention should be focused on restoring ventilation, as these are primary respiratory arrests.

I wonder if a lot of the arguments like this that we get into on this forum stem from our boards preparation where we're forced to choose "the most appropriate initial action". In real life, I never do just one thing. In a real code, my team and I are doing about a half a dozen things in parallel (narcan, compressions, ventilation, getting the patient on the monitor, pulling up the latest discharge sumarry, getting additional IV access, etc).

Oh I absolutely am advocating for withholding Narcan during opiate-related codes.

Lets go down the rabbit hole...

1. Opiates cause respiratory depression leading to hypoxemia and hypoxia leading to PEA and DEATH yada yada yada.

2. The fastest and most effective treatment for hypoxia (which is actually hurting the patient not respiratory depression) is ventilation and oxygenation.

3. Opiates do not interfere with rescuer ventilation nor oxygenation and as a result both work to rapidly reverse (much like an antidote) the opiate induced hypoxia.

4. The effects of ventilation and oxygenation can be easily and reliably obtained without the use of adjunct therapies such as Narcan in patients when the drug is not available.

5. Narcan has an onset of action of 1-2min when given IV (which is likely 2-3min in PEA with poor perfusion) and as such it is physiologically impossible for someone to respond immediately after administration (which is why you're supposed to wait 2-3min between doses). The much more likely and physiologically plausible explanation was that the patient who had been getting ventilation and oxygenation long before getting Narcan responded to the first intervention.

6. Narcan is not a completely benign medication and as you already know and has a long list of dangerous and deadly adverse effects (especially with high doses given in codes) including: seizures, nausea, vomiting, pulmonary edema, ventricular tachycardia, ventricular fibrillation, and cardiac arrest. None of these things (especially the last 3 ones) seem like a good idea during codes especially when there is already a safe and effective treatment available.

So to summarize we have a medication that:

A) has never been shown to provide any additional benefit to ventilation and oxygenation for patients in cardiac arrest

and

B) has been shown to cause multiple serious and potentially life threatening adverse effects


Finally I'll offer a personal anecdote. About 12 years ago back when I was a FF/EMT in South Carolina (long before Narcan kits were found in every fire truck and police cruiser) we used to routinely manage opiate overdoses (including cardiac arrests) with nothing but a BVM. Not surprisingly these patients all did very well provided we got there in time and provided effective ventilation and oxygenation. As one of my favorite toxicology professors (and probably the smartest EM physician i've ever met in my life) likes to say: "opiate overdose causes hypoxia and the antidote for hypoxia is ventilation not Narcan."

 

[alpinism]

**As a follow up to the prior post and before everyone jumps on me I'm not advocating for never giving Narcan but rather for using it as an adjunct to reverse the respiratory depression AFTER the patient has been appropriately ventilated and oxygenated to reverse the life threatening hypoxia in overdose patients.**

 

[Siggy]

As an IM resident applying to critical care, given the patient in the original post, I would judge the management based on 2 questions.

1. Is the patient protecting their airway? If not, then they should have intubated. Given the outcome, I'm going to guess that it's a "yes." As an aside, "protecting the airway" is the proper question, not "what is the GCS?" (i.e. "less than 8, intubate). This question is also colored by what the overnight staffing situation is (i.e. 24 hour intensivist coverage vs day coverage, night time on-call vs no intensivist). Less coverage, more likely to intubate. It's not nice to take off at 6pm and have the ED intubating an ICU patient at 6:30.

2. Do I have a cause for the altered mental status? In this case, yes... encephalopathy due to benzos plus/minus opiates. I'm assuming that the basic AMS workup is otherwise negative (i.e. chem panel, CBC, CT brain).

Often less is more. Don't let perfect be the enemy of good.

 

[BAM!]

"opiate overdose causes hypoxia and the antidote for hypoxia is ventilation not Narcan."

not to be a stickler, but... the antidote for hypoxia is oxygen. The antidote for hypercapnea is ventilation. and the antidote for opiate overdose is Narcan. Every time I've given Narcan, they're better in 20 seconds or less. And it's fun to watch them wake up.

yes, they often feel awful. Has anyone ever seen a serious side effect from Narcan administration in a straight forward opiate overdose?

 

[Rendar5]

not to be a stickler, but... the antidote for hypoxia is oxygen. The antidote for hypercapnea is ventilation. and the antidote for opiate overdose is Narcan. Every time I've given Narcan, they're better in 20 seconds or less. And it's fun to watch them wake up.

yes, they often feel awful. Has anyone ever seen a serious side effect from Narcan administration in a straight forward opiate overdose?

I have had a patient before with acute pulmonary edema requiring intubation before. This happened approximately 30 minutes after arrival patient had been wide-awake. Non-cardiogenic pulmonary edema is associated with high doses of narcan and there is some debate over whether The opiate or the narcan isthe causative agent. that said, this is rather rare. I personally have no issues with narcan use, but there is also nothing wrong with just ventilating them until they come around for simple overdose.

 

[alpinism]

not to be a stickler, but... the antidote for hypoxia is oxygen. The antidote for hypercapnea is ventilation. and the antidote for opiate overdose is Narcan. Every time I've given Narcan, they're better in 20 seconds or less. And it's fun to watch them wake up.

yes, they often feel awful. Has anyone ever seen a serious side effect from Narcan administration in a straight forward opiate overdose?

This is true.

Luckily air on the planet earth contains oxygen which is transmitted to your lungs during ventilation.

 

[TooMuchResearch]

I have had a patient before with acute pulmonary edema requiring intubation before. This happened approximately 30 minutes after arrival patient had been wide-awake. Non-cardiogenic pulmonary edema is associated with high doses of narcan and there is some debate over whether The opiate or the narcan isthe causative agent. that said, this is rather rare. I personally have no issues with narcan use, but there is also nothing wrong with just ventilating them until they come around for simple overdose.

I had a similar case a few months ago.

 

[Zebra Hunter]

Also a huge pet peeve and completely agree.





Oh I absolutely am advocating for withholding Narcan during opiate-related codes.

Lets go down the rabbit hole...

1. Opiates cause respiratory depression leading to hypoxemia and hypoxia leading to PEA and DEATH yada yada yada.

2. The fastest and most effective treatment for hypoxia (which is actually hurting the patient not respiratory depression) is ventilation and oxygenation.

3. Opiates do not interfere with rescuer ventilation nor oxygenation and as a result both work to rapidly reverse (much like an antidote) the opiate induced hypoxia.

4. The effects of ventilation and oxygenation can be easily and reliably obtained without the use of adjunct therapies such as Narcan in patients when the drug is not available.

5. Narcan has an onset of action of 1-2min when given IV (which is likely 2-3min in PEA with poor perfusion) and as such it is physiologically impossible for someone to respond immediately after administration (which is why you're supposed to wait 2-3min between doses). The much more likely and physiologically plausible explanation was that the patient who had been getting ventilation and oxygenation long before getting Narcan responded to the first intervention.

6. Narcan is not a completely benign medication and as you already know and has a long list of dangerous and deadly adverse effects (especially with high doses given in codes) including: seizures, nausea, vomiting, pulmonary edema, ventricular tachycardia, ventricular fibrillation, and cardiac arrest. None of these things (especially the last 3 ones) seem like a good idea during codes especially when there is already a safe and effective treatment available.

So to summarize we have a medication that:

A) has never been shown to provide any additional benefit to ventilation and oxygenation for patients in cardiac arrest

and

B) has been shown to cause multiple serious and potentially life threatening adverse effects


Finally I'll offer a personal anecdote. About 12 years ago back when I was a FF/EMT in South Carolina (long before Narcan kits were found in every fire truck and police cruiser) we used to routinely manage opiate overdoses (including cardiac arrests) with nothing but a BVM. Not surprisingly these patients all did very well provided we got there in time and provided effective ventilation and oxygenation. As one of my favorite toxicology professors (and probably the smartest EM physician i've ever met in my life) likes to say: "opiate overdose causes hypoxia and the antidote for hypoxia is ventilation not Narcan."

For the millionth time, no one (including myself) is advocating against rescue ventilation. I use BVM for every single one of my opiate overdoses. And no, it is not physiologically impossible for a drug to work quicker than its reported onset of action. Narcan frequently works within 30 seconds.

As for the side effects, come on, man. Nausea and vomiting is a lot better than dead. And when have you or anyone on here ever seen someone have a narcan induced cardiac arrest or v-tach/v-fib? As for pulmonary edema, it's incredibly questionable whether that is actually caused by narcan given that opiate related pulmonary edema has been reported since before narcan was ever even invented. Also, I think citing side effects as a reason not to give a drug in a code is kind of absurd, but if you want to go down that route, think about the complications caused by intubation and mechanical ventilation, as well.

Just give the dang drug.

Naloxone in cardiac arrest with suspected opioid overdoses. - PubMed - NCBI

RESULTS:
Fifteen of the 36 (42%) (95% confidence interval [CI]: 26-58) patients in cardiac arrest who received naloxone in the pre-hospital setting had an improvement in electrocardiogram (EKG) rhythm. Of the participants who responded to naloxone, 47% (95% CI: 21-72) (19% [95% CI: 7-32] of all study subjects) demonstrated EKG rhythm changes immediately following the administration of naloxone.
DISCUSSION:
Although we cannot support the routine use of naloxone during cardiac arrest, we recommend its administration with any suspicion of opioid use. Due to low rates of return of spontaneous circulation and survival during cardiac arrest, any potential intervention leading to rhythm improvement is a reasonable treatment modality.

 

[alpinism]

For the millionth time, no one (including myself) is advocating against rescue ventilation. I use BVM for every single one of my opiate overdoses. And no, it is not physiologically impossible for a drug to work quicker than its reported onset of action. Narcan frequently works within 30 seconds.

As for the side effects, come on, man. Nausea and vomiting is a lot better than dead. And when have you or anyone on here ever seen someone have a narcan induced cardiac arrest or v-tach/v-fib? As for pulmonary edema, it's incredibly questionable whether that is actually caused by narcan given that opiate related pulmonary edema has been reported since before narcan was ever even invented. Also, I think citing side effects as a reason not to give a drug in a code is kind of absurd, but if you want to go down that route, think about the complications caused by intubation and mechanical ventilation, as well.

Just give the dang drug.

Naloxone in cardiac arrest with suspected opioid overdoses. - PubMed - NCBI

RESULTS:
Fifteen of the 36 (42%) (95% confidence interval [CI]: 26-58) patients in cardiac arrest who received naloxone in the pre-hospital setting had an improvement in electrocardiogram (EKG) rhythm. Of the participants who responded to naloxone, 47% (95% CI: 21-72) (19% [95% CI: 7-32] of all study subjects) demonstrated EKG rhythm changes immediately following the administration of naloxone.
DISCUSSION:
Although we cannot support the routine use of naloxone during cardiac arrest, we recommend its administration with any suspicion of opioid use. Due to low rates of return of spontaneous circulation and survival during cardiac arrest, any potential intervention leading to rhythm improvement is a reasonable treatment modality.

Heh I was hoping you'd post that study.

Did you even read it or just look at the abstract?

First of all it was a retrospective chart review which by definition cannot prove causation.
Second of all random EKG changes are not a patient centered outcome in the management of cardiac arrest patients.
Regardless of the above Naloxone did not demonstrate a significant improvement in survival or neurologically intact survival in the study.

 

[WilcoWorld]

I try not to let fear of litigation motivate my care.

That being said, if you want to get sued, withholding naloxone in an opiate/opioid-related arrest is a GREAT way to set yourself up to loose.

 

[Zebra Hunter]

Heh I was hoping you'd post that study.

Did you even read it or just look at the abstract?

First of all it was a retrospective chart review which by definition cannot prove causation.
Second of all random EKG changes are not a patient centered outcome in the management of cardiac arrest patients.
Regardless of the above Naloxone did not demonstrate a significant improvement in survival or neurologically intact survival in the study.

Your critique makes no sense. It was a retrospective chart review with no control group looking only at cardiac rhythm. Your point that it did not show significant improvement in survival makes no sense, that's not what the study was looking at and it was not designed to determine improvement in patient centered outcomes since there is no control group. The point of my post is that there is at least some evidence (albeit low quality) that appears to demonstrate some potential benefit to narcan in cardiac arrest. You will never get a prospective, controlled study because it would be inappropriate to withhold narcan in an opiate related cardiac arrest.

If you'd like to put your liscense on the line withholding life saving medication due to an opinion lacking any evidence, just know that you will have very few physicians that would back up your opinion, and plenty that would be willing to testify against you. When there is no way to make a patient more dead by giving a medication and that medication is strongly recommended and has a theoretical benefit, you'd be insane not to give it. Do you withhold ACLS meds, too, despite their proven lack of efficacy? Somehow I doubt that you're telling your nurses to hold off on the epi in a cardiac arrest.

 

[Janders]

(1) I've seen a couple cases of post-heroin-narcan-rescue pulmonary edema. A couple needed bipap, never had to tube one personally but have heard accounts of that.
(2) Does narcan do anything else to help us during an arrest? Does it reverse any of the opiate-induced hypotension? or does it only bring back the ventilatory drive?

I certainly use in during arrests. I'd rather BVM and give narcan and hopefully the patient is up and cussing at me in 2 minutes versus intubate, ventilate, get ROSC but have no mental status because they are intubated and then leave them on the vent for a couple hours until the heroin wears off. I get that you can successfully manage and arrest WITHOUT it, but I like taking the opiate-effects off the table...