Fentanyl Cross Contamination

[ThadeusJ]

Here's an interesting scenario we were asked about: The recent spate of fentanyl and carfentanil overdoses have been associated with at least two health care providers (here and here) being exposed and treated for opioid toxicity after a response. It has been suggested that first responders not commit to CPR if they feel that there is a risk of contamination and they are not properly equipped.

Alberta Health Care has released a pretty decent guide for EMS and first responders and suggest that those performing CPR where there is a chance of carfentanil exposure double glove (5 mm extended length if handling pills), wear eye protection or without a faceshield, gown, etc. and use a CPR mask or BVM with providing ventilatory support.

Question to the group: what do you think is the most culpable source of fentanyl/carfentanil cross contamination (eyes, skin, inhaled, other?) in situations such as this such that we could identify the weakest component of their PPE?

I think the original question I was presented with was for layperson CPR and the integrity of the equipment they may have available.

 

[EpiEMS]

For what it's worth, the American Academy of Clinical Toxicologists has issued a position paper stating, among other things, that "[f]entanyl and its analogs are potent opioid receptor agonists, but the risk of clinically significant exposure to emergency responders is extremely low."

NIOSH advises "use of a P100-rated respirator, nitrile gloves, and eye protection".

The AACT seems to suggest that dermal absorption is not likely to be a big problem ("it is very unlikely that small, unintentional skin exposures to tablets or powder would cause significant opioid toxicity, and if toxicity were to occur it would not develop rapidly, allowing time for removal"). Not to mention, if you're wearing gloves, you should be fine. I'd be more worried about respiratory exposure or mucous membrane exposure.

For layperson CPR, just don't ventilate - problem solved. Your mucous membranes, eyes, etc. are pretty safe there, then, no? For health care provider CPR - mask or BVM.

 

[Carlos Danger]

Question to the group: what do you think is the most culpable source of fentanyl/carfentanil cross contamination (eyes, skin, inhaled, other?)

Respiratory. Dermal is not a plausible route.

 

[EpiEMS]

Dermal is not a plausible route.

Apropos to this, the position paper I cited earlier notes:

However, incidental dermal absorption is unlikely to cause opioid toxicity. If bilateral palmar surfaces were covered with fentanyl patches, it would take approximately 14 minutes to receive 100 mcg of fentanyl [using a body surface area of 17,000 cm2 , palm surface area of 0.5% [26], and fentanyl absorption of 2.5 mcg/cm2 /h [24]. This extreme example illustrates that even a high dose of fentanyl prepared for transdermal administration cannot rapidly deliver a high dose.