***DISCLAIMER*** (1000 - 6/10/18)
I felt the need to place a disclaimer at the beginning of this article because of a number of people taking this blog the wrong way. This article is not suggesting we take naloxone off of the ambulances or out of the ED. It is meant to make us evaluate how we feel about airway management in overdose patients. I use rather strong wording in this article and make rather black and white statements because I want people to be on one side or the other by the time they reach the end. This is not to cause division, but to force us to evaluate and reevaluate the way we are treating the growing number of overdose victims to be sure we are giving the the most optimal care possible. There is not one perfect solution, and solutions will be very service and area specific. Read this article with a grain of salt, as some will find it to be rather inflammatory. This article aims to start the conversation about if having both providers on scene 100% focused on airway management may be better than having divided roles - one doing perhaps subpar airway management while another is focused on a completely different task. The answer to 'should we give naloxone or not?' should be answered after the patient is oxygenated and ventilated. Please keep in mind and respect that some protocols have already gone to an 'airway only' approach, setting aside the naloxone for unresponsive patients (we are talking about unresponsive patients here). At the end of this article you will either be more convinced that what you are doing is right, or you will start to question the status quo. Cheers!
***END OF DISCLAIMER***
About a month ago, the president of my company asked me to do an interview about Fentanyl / Naloxone for a local news outlet. I think he was slightly unsure about what I was going to say in this interview... I prepared very well for this interview and actually brought about 10 pages of resources for the news crew to read - so they could get some factual information about the fentanyl exposure and naloxone use. Unfortunately, the interview never happened. I was about 3 blocks away from the news station when I got a call saying they they were going out on a call for some breaking news. So it goes. I was disappointed I didn't get to share my point of view on this subject, but relieved I didn't have to go on camera. I continue to see this topic of opioid overdose come up - and so it should! There is clearly an opioid epidemic that is going on. No one can deny that! My issue is not one of questioning the opioid epidemic. My issue is that we are treating these patients all wrong.
Naloxone is an Amazing Drug
Seem counterproductive to my main point? It's not. Naloxone is so amazing that the effect this medication has on people seems nothing short of magical. There are not many medications that we give that have such a profound, obvious, and sometimes shocking effect on a patient. It seems like a miracle when they go from completely unresponsive to talking in a matter of a minute - and YOU look like the hero! You might say: 'YEAH! The stuff works great!' However, other providers might say: 'That is not a good thing...' What's up with the difference in opinions?
What are we teaching people?
All this hype about naloxone is teaching people that naloxone is the cure for opioid overdose. It's not. We have to get back to what kills these patients. What kills these patients is simple - hypoxia secondary to hypoventilation. What is the cure for someone who is not breathing adequately? Breathe for them! You don't even need a BVM to do this. You can teach people to use a pocket mask (and some pocket masks even have oxygen attachments). We have people paying through the nose for naloxone because it's the new and cool thing, when they should actually be using a $5.00 pocket mask. 'But Sam, doesn't naloxone make the patient breathe on their own??' Yeah, sometimes.
For a patient with a hefty dose of opioids on-board, the dose of naloxone someone administers may not be enough. What happens if the naloxone doesn't work? The naloxone may take an even longer time to kick in adequately if you are giving very low dose (although probably more responsible) dosing. What have we trained people to do if the naloxone doesn't work or if it seems to be taking forever? Absolutely nothing. And if a person does happen to have a CPR certification, they often get so side tracked by naloxone that they will completely forget about rescue breathing. A patient is sitting in front of these people (sometimes EMS included) not breathing, and people are worried about getting naloxone on board. Any opioid overdose can be fixed with a pocket mask, it works every time, without delay. Anyone who can figure out how to give naloxone can be taught how to administer a breath. First responders who cannot intubate should perhaps focus on providing rescue breaths until an airway trained provider arrives - making naloxone their second priority (to ensure good airway management is being performed)
Are You Serious? Why not just reverse the overdose?
Why not just reverse the overdose? When I bring this crazy idea up of breathing for a patient who isn't breathing, I always get pushback. There are at least a hand full of things to consider before giving naloxone.
1. You have absolutely no idea who is on the other side of that overdose. People are hyper-obsessed with scene safety in relation to drugs on scene (which is completely unfounded, see links below). There are no documented cases of people actually overdosing from touching fentanyl (again, see resources below). But does anyone ever stop to think that the patient might make the scene unsafe after naloxone? There is no shortage of stories about people waking up an overdose patient and then that patient becoming violent and attacking EMS. I know this doesn't happen all the time, but it does happen occasionally. Has anyone searched this patient for weapons before administering naloxone? I'm willing to bet that never happens with how naloxone trigger-happy everyone is.
2. You have absolutely no idea what they have in their system. So your patient took an extremely high dose of Fentanyl laced heroin. They have pinpoint pupils, a depressed respiratory rate, and are very hypoxic. 'That's an easy one...' You give a bunch of naloxone, only to find out that they also took a bunch of crack cocaine and are now freaking out in the back of your ambulance. I would rather deal with the sedated version of this patient.
3. You have absolutely no idea where they will go next. True story: One afternoon an EMS crew responds to a gas station for an unresponsive patient. The patient is revived by naloxone by the crew. The patient is now A/Ox4, and completely his own person, able to leave AMA in his car. The patient would not provide the crew with any information, and left. Later that evening, another call comes out for an unresponsive man at his residence. The crew responds to find the same man from the gas station, now PNB. He likely overdosed again after driving home, where no one found him until hours later when his friend walked into his house. If only he was intubated, transported, slowly allowed to come out of his drug-induced coma, and then offered treatment options. Maybe he would still be alive. Data is still out on safety of naloxone sign-offs.
4. You can land them in the ICU. Not many people know that naloxone can give you flash pulmonary edema through more than one mechanism. The first mechanism is simply sympathetic overdrive from a dump of catecholamines (basically turning the patient into a S.C.A.P.E. patient). The other is something called negative pressure pulmonary edema. This one is very interesting. For a little experiment, completely block your nose and close your mouth, and then try to take a gentle breath in. Uncomfortable? It's a very weird feeling. Now imagine that your patient doesn't have conscious airway control of their upper airway, and then take a large forceful breath in while their airway is closed. This causes a negative pressure in the lungs that draws fluid in. This is the result of not managing an airway prior to giving naloxone, and it could make them hard to oxygenate.
5. You may give them a severe withdrawal symptoms, and maybe a seizure. Acute withdrawal symptoms are no joke. They include severe pain, nausea, vomiting, tremors, diarrhea, panic, and even seizures on rare occasion. This usually results from a catecholamine dump, which is also going to cause tachycardia, hypertension, and tachypnea. This is going to put your previously hypoxic patient into an increased metabolic rate where they need more oxygen. This could place them at increased risk of heart and brain ischemia. Definitely something to think about.
Well, Don't give em' THAT MUCH!
Ah yes, the ol' slow reversal. I smell what you're steppin' in. I'm going to give you a quick scenario. You arrive on scene to a patient that is responsive to pain. They are breathing at 8 times per minute, not controlling their secretions, and not producing any noise. What do you do? Any responsible provider would then secure this patients airway. A person who cannot phonate or swallow secretions should be intubated without delay (obviously with appropriate oxygenation and denitrogenation prior to the procedure). What's the point? This is common sense.
The point is that a respiratory rate of 8 is what many protocols will try to get you to titrate your naloxone to. Great idea! Let's give them just enough naloxone to obtain a barley adequate respiratory rate and sluggish-at-best airway control. If we're lucky they will get nauseated without being able to tell us and then Jimi Hendrix right in front of us so that we can Jimi DuCanto SALAD the airway for practice.
My point is that it can be very difficult to titrate the naloxone to an adequate respiratory rate. And even if we do, are their airway reflexes truly secure at that level of consciousness? Probably not. I have my doubts about the adequacy of the airway management being performed on these calls while people wait for the naloxone to kick in. As an alternative, we could have both providers focused on the airway and ensuring that ventilation and oxygenation are adequately performed (taking some of the focus off of naloxone).
Alright, the airway is now secure, they're oxygenating well, and their ETCO2 is coming down. Now what? ...
You have just fixed what kills patients from opioid overdose. Transport them so that they can slowly and safely come out of their overdose and possibly get help for their addiction.