Pulling the plug on EMS
- Thread starter Veneficus
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18G
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NPA, BVM, and suction is supportive care in an opioid OD until the effects can be reversed. Narcan treats the OD and fixes the problem.
This is so elementary.
This is so elementary.
82nd medic
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Fluids, suction, an NPA and BVM?
True, but autoinjectors make layperson administration a real posibility
I think what he's saying is EMS does a very poor job at intubation, and the cost/benefit of maintaining a proper program doesn't add up, especially considering the decreasing need for intubation.
Much of EMS in Europe is physician-based, the majority that isn't is nurse-based. Meaning it's far from load and go, and is more like to offer definitive treatment and outcome in the field.
How do patients live without this never proven to helpful, proven to be harmful, usually improperly applied, and painful treatment! Yet there doesn't seem to be a overabundance of paraplegics in continental Europe....
I think you need to do a little more research on US EMS vs EMS abroad.
Resp distress isn't the only side effects of Opiod poisoning. What are those treatments going to do for bradychardia or hypotension? Fluids are a medication btw.
Out of the military how many lay persons carry atropine or know the S/S of nerve agents?
Intubation causes less damage than king lts/combi tubes. Yes those are quicker and easier but if you have time: why not be safe?
I'm just going off of what my UK born instructor said.
Spinal immobilization is hazardous? Last I checked a broken bone that's stabilized poses less of a risk of further damage than one that's not. I've yet to see anything showing that it poses more of a risk than a prevention. Being strapped down to a spine board isn't any more painful than bouncing around in the back of an ambulance would be.
I have no clue about paraplegics, but in 2006 1:36.6 car crashes in Europe resulted in fatalities. The ratio of injured to killed was 48.5:1. In 2005, only 1:150 car crashes in the US resulted in fatalities. The ratio of injured to killed was 68:1. Statistically speaking, were doing something right.
I'm all for progression, I was stoked when civie EMS finally moved major bleeding to the front of the list and stopped that whole "tourniquets are a last result" bs. But arguing for progression and arguing for making EMS just delivery-boys and saying that medications that are proven to have saved lives is another
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18G
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No,the issue isn't clearing the opioid from the body. Ultimately that is what is desired but the problem that results in need for treatment is the respiratory depression, airway compromise, and bradycardia.
Narcan is the definitive treatment because it restores breathing, improves airway, and secondarily increases heart rate.
Narcan is not supportive.
Narcan is the definitive treatment because it restores breathing, improves airway, and secondarily increases heart rate.
Narcan is not supportive.
82nd medic
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You're not limited to one dose. If it wears off push in another. A large percentage of medicine is just treating the symptoms until the body can heal itself, that's what Opiod antagonists do: they manage the possibly fatal side effects until the body removes the source.
JPINFV
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So, anything close to a majority of patients you c-spine have a spinal injury?
It makes sense to strap a normally curved structure to a flat board?
There's evidence that spinal immobilization decreases secondary spinal injury?
Malaysian/University of New Mexico retrospective chart review: http://onlinelibrary.wiley.com/doi/10.1111/j.1553-2712.1998.tb02615.x/abstract
Outcome, no benefit.
"The effect of spinal immobilization on healthy volunteersType of participants: Twenty-one healthy volunteers with no history of back disease.
Interventions: Subjects were placed in standard backboard immobilization for a 30-minute period. Number and severity of immediate and delayed symptoms were determined.
Measurements and main results: One hundred percent of subjects developed pain within the immediate observation per iod. Occipital headache and sacral, lumbar, and mandibular pain were the most frequent symptoms. Fifty-five percent of subjects graded their symptoms as moderate to severe. Twenty-nine percent of subjects developed additional symptoms over the next 48 hours.
Conclusion: Standard spinal immobilization may be a cause of pain in an otherwise healthy subject."
http://www.sciencedirect.com/scienc...35221faae7006f0e68a60164a846d51c&searchtype=a
"We conclude from our data that these devices produce a significantly restrictive effect on pulmonary function in the healthy, nonsmoking man."
-http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB0-4G9CB76-D&_user=945451&_coverDate=09%2F30%2F1988&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_searchStrId=1708467727&_rerunOrigin=scholar.google&_acct=C000048962&_version=1&_urlVersion=0&_userid=945451&md5=53df0436f30430badda5e47cb9251fdd&searchtype=a
"Spinal immobilization significantly reduced respiratory capacity as measured by FVC in healthy patients 6 to 15 years old. There is no significant benefit of one strapping technique over the other."
-http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WB0-4G82KTB-J&_user=945451&_coverDate=09%2F30%2F1991&_rdoc=1&_fmt=high&_orig=gateway&_origin=gateway&_sort=d&_docanchor=&view=c&_searchStrId=1708467753&_rerunOrigin=scholar.google&_acct=C000048962&_version=1&_urlVersion=0&_userid=945451&md5=88ea3a5b2f9bdbd0e50e6afd483bc97e&searchtype=a
So, now show me a study where spinal immobilization improves outcomes.
Which an NPA, suction, BVM(more often just a little stimulation) and fluid can do more cheaply with a better side effect profile right?
18G
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Are you discussing this and giving your thoughts objectively or are you trying to stay on the good side of certain people?
Narcan is not an expensive drug. And why not acknowledge what happens when you BVM a patient for 30mins? Is it warranted to create a potential for further airway compromise and aspiration needlessly when we can quickly give a medication which will allow the patient to breathe on their own and manage their own airway?
I can manage an opiate OD much more safely and efficiently with Narcan then I can with having to monitor the provider doing the ventilating, suctioning the patient, dealing with puke, giving fluids, placing an NG tube, etc etc etc.
Doesn't anyone else see how much more involved this is?
Hospitalization from infection because the patient aspirated because we caused the patient to vomit through prolonged BVM ventilation doesn't seem like a real good side effect profile to me.
Narcan virtually has no side effects in and of itself which is the beauty of it. It's extremely safe , fast acting, and highly effective.
And what sense does it make to BVM a patient the entire transport time, suction, place an NG tube, etc when as soon as you roll in the door at the ED, the patient is going to get Narcan any way.
Field Narcan or ED Narcan? What is the difference? The patient needs it which is why they get it right away in the ED!
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truetiger
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I don't think "it's cheaper" is going to cut it when the patient aspirates.
Opioid OD research tonight.
Ok, firstly I do not plan to write a paper on this, so I will try to sum it up as best I can in a page.
I acknowledge that Harrison's internal medicine lists an antagonist as definitive treatment for opioid overdose. However, medicine is rarely simple, and this is no exception.
Of the 5 resources I checked (4 books and the chief of anesthesia who is one of my academic advisors) All except Harrison's clearly demonstrated that
1. Naloxone was studied and listed as safe treatment for accidental overdose in healthy individuals. (non opioid dependant)
2. The definitive treatment with naloxone is an infusion, that is needed to outlast the specific opioid. (between 6 and 72 hours) The effects of naloxone between 1-4 hours.
3. Caution must be execised in the use of naloxone in opioid dependant overdoses with sub Q (you may recall IV is much more rapid.) doses as little as 0.5mg can precipitate severe withdrawel in as little as 2 hours which will require intensive therapy. The recommended dose is 0.4mg/500ml and run "slowly." (whatever the hell that means, but the advice I got was over 1.2 to an hour)
4. There are multiple types, (3) to be exact, of opioid toxicity. Of which 1 has a mechanism that is unresponsive to naloxone treatment.
The primary pathology of opioid overdose is disruption of the breathing pattern from action on medularly chemoreceptors. Specifically opioid inhibits the breathing response to increased pCO2. The hypotension and bradycardia are subsequent to this respiratory depression and reverse themselves by correcting it.
Additionally, with the depression of pCO2 control, the body reverts to pO2 for respiratory drive. High dose oxygen is considered relatively contraindicated as it may knock out all intrinsic respiratory effort.
The Opioid toxicity which is unresponsive to Naloxone is from direct stimulation of mast cells resulting in shock from an anaphylactoid reaction. Treatment as per distributive shock.
Among the listed effects of acute opioid withdrawel are: rebound CNS activity, arrhythmia, and pulmonary edema.
There is some dispute as to whether this pulmonary edema is caused from the reversal, the offending opioid, or aspirated stomach contents. (It is my observation when there are multiple disputed mechanisms, it is usually a combination) In any event, positive pressure ventilation is listed as the treatment of choice. (from the earlier discussion, probably without supplemental oxygen would be best)
So how does this all play out?
Basically, most of the sequele is mitigated by ventilatory support, which is listed as the primary emergency treatment everywhere. The bradycardia as well as hypotension in early intervention are resolved by ventilation.
Late presentation of opioid OD includes findings of shock and dialated pupils from progressive shock, which must be treated like any other distributive hypotension. Especially in the case of anaphylactoid reaction.
In order to prevent aspiration and its subsequent sequele, the reversal agent may (nobody knows) have to be given prior to relaxation of the esophageal sphincters as the aspiration may be sub clinical and not gross vomitus. additionally vomiting may a side effect of acute reversal in chronic users and intubation for aspiration airway protection indicated.
Because of the risk relapse given the naloxone life, a period of observation will have to be undertaken commensurant with the specific agent. So at least an ED or ward bed will be taken for 6+ hours.
Chronic substance abusers who OD will have to be admitted, I am told most beneficially to the ICU for a slower approach and management of these patients.
I was told I covered quite well my lessons of acutely reversing deleterious effects of analgesia so I will not rehash it here.
Additionally I am told, in the event of an actual or suspected oral opioid OD, lavage will be a treatment. NG/OG for decompression of those who do wind up in ICU is common practice.
So the questions then becomes:
Does EMS intervene fast enough to prevent aspiration in opioid OD?
Does the field administration of naloxone in the chronic abuser do more harm than good? (consider it may take ~2 hours for the onset of withdrawl symptoms, well beyond the average time EMS is with a patient)
Are EMS providers capable or proficent to use an infusion of naloxone?
It would seem that if EMS providers are identifying opioid OD by pinpoint, rather than dialated pupils and not treating for hypotension of progressive shock, they may still be (again nobody knows) arriving early enough to manage the respiratory compromise and let the hypotension and bradycardia reverse themselves.
However, given the information about the effect of supplemental oxygen on knocking out what I will call the hypoxic drive of opioid OD, it raises the spectre that the initial method of managing the respiratory depression maybe iatrogenic, which leads to the perceived need for a reversal agent.
Now what? Back where we started.
Ok, firstly I do not plan to write a paper on this, so I will try to sum it up as best I can in a page.
I acknowledge that Harrison's internal medicine lists an antagonist as definitive treatment for opioid overdose. However, medicine is rarely simple, and this is no exception.
Of the 5 resources I checked (4 books and the chief of anesthesia who is one of my academic advisors) All except Harrison's clearly demonstrated that
1. Naloxone was studied and listed as safe treatment for accidental overdose in healthy individuals. (non opioid dependant)
2. The definitive treatment with naloxone is an infusion, that is needed to outlast the specific opioid. (between 6 and 72 hours) The effects of naloxone between 1-4 hours.
3. Caution must be execised in the use of naloxone in opioid dependant overdoses with sub Q (you may recall IV is much more rapid.) doses as little as 0.5mg can precipitate severe withdrawel in as little as 2 hours which will require intensive therapy. The recommended dose is 0.4mg/500ml and run "slowly." (whatever the hell that means, but the advice I got was over 1.2 to an hour)
4. There are multiple types, (3) to be exact, of opioid toxicity. Of which 1 has a mechanism that is unresponsive to naloxone treatment.
The primary pathology of opioid overdose is disruption of the breathing pattern from action on medularly chemoreceptors. Specifically opioid inhibits the breathing response to increased pCO2. The hypotension and bradycardia are subsequent to this respiratory depression and reverse themselves by correcting it.
Additionally, with the depression of pCO2 control, the body reverts to pO2 for respiratory drive. High dose oxygen is considered relatively contraindicated as it may knock out all intrinsic respiratory effort.
The Opioid toxicity which is unresponsive to Naloxone is from direct stimulation of mast cells resulting in shock from an anaphylactoid reaction. Treatment as per distributive shock.
Among the listed effects of acute opioid withdrawel are: rebound CNS activity, arrhythmia, and pulmonary edema.
There is some dispute as to whether this pulmonary edema is caused from the reversal, the offending opioid, or aspirated stomach contents. (It is my observation when there are multiple disputed mechanisms, it is usually a combination) In any event, positive pressure ventilation is listed as the treatment of choice. (from the earlier discussion, probably without supplemental oxygen would be best)
So how does this all play out?
Basically, most of the sequele is mitigated by ventilatory support, which is listed as the primary emergency treatment everywhere. The bradycardia as well as hypotension in early intervention are resolved by ventilation.
Late presentation of opioid OD includes findings of shock and dialated pupils from progressive shock, which must be treated like any other distributive hypotension. Especially in the case of anaphylactoid reaction.
In order to prevent aspiration and its subsequent sequele, the reversal agent may (nobody knows) have to be given prior to relaxation of the esophageal sphincters as the aspiration may be sub clinical and not gross vomitus. additionally vomiting may a side effect of acute reversal in chronic users and intubation for aspiration airway protection indicated.
Because of the risk relapse given the naloxone life, a period of observation will have to be undertaken commensurant with the specific agent. So at least an ED or ward bed will be taken for 6+ hours.
Chronic substance abusers who OD will have to be admitted, I am told most beneficially to the ICU for a slower approach and management of these patients.
I was told I covered quite well my lessons of acutely reversing deleterious effects of analgesia so I will not rehash it here.
Additionally I am told, in the event of an actual or suspected oral opioid OD, lavage will be a treatment. NG/OG for decompression of those who do wind up in ICU is common practice.
So the questions then becomes:
Does EMS intervene fast enough to prevent aspiration in opioid OD?
Does the field administration of naloxone in the chronic abuser do more harm than good? (consider it may take ~2 hours for the onset of withdrawl symptoms, well beyond the average time EMS is with a patient)
Are EMS providers capable or proficent to use an infusion of naloxone?
It would seem that if EMS providers are identifying opioid OD by pinpoint, rather than dialated pupils and not treating for hypotension of progressive shock, they may still be (again nobody knows) arriving early enough to manage the respiratory compromise and let the hypotension and bradycardia reverse themselves.
However, given the information about the effect of supplemental oxygen on knocking out what I will call the hypoxic drive of opioid OD, it raises the spectre that the initial method of managing the respiratory depression maybe iatrogenic, which leads to the perceived need for a reversal agent.
Now what? Back where we started.
Sasha
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I always appreciate a Woman's opinionbut that is not what Vene is doing.
Maybe we should also allow patient's to bleed and allow the body's own hemostatic mechanisms to stop the bleeding. After all our goal is to always do the bare minimum to care for our patients.
There you go taking things to the extreme. Stop looking at things as either black or white and use your brain to figure out when less is more and when you need to intervene. Come on, youre smarter than that.
lightsandsirens5
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What I don't understand is why you would not want to restore a pts respiratory drive when you can do so with a cheap and effective drug that has been proven safe for many years. In fact, the only contra for Narcan is allergy to said drug, correct? As far as I have found, there are no cases of Narcan allergy.
I don't see how that is a bad thing. You give the Narcan until the pts respiratory drive is restored, no more. No violent pt, no puke to clean up, and yet at the same time I don't have to bag some body, I don't have to maintain their airway for them, they do it! And life is good, yes yes? I know there are providers who use it to punish people. That is wrong, I agree. But a proven safe, effective and simple drug in the hands of field EMS personnel is about as non traumatic, non invasive as it gets. Ok, maybe bagging is less invasive, but have any of you attempted to bag someone for 90 minutes, by yourself, in the back of an ambulance while stuck in a snowstorm? It would wear you down! Yet with Narcan, my pt was breathing by himself, and all I had to to was monitor him.
I often agree with Vene, but I simply cannot see the logic behind this argument. I really can't even see the true argument. Why in the case of a simple, cut and dried narcotic OD would you not use a simple, time tired and proven procedure to correct (temporarily I admit) the problem until the body can correct the problem itself?
I don't see how that is a bad thing. You give the Narcan until the pts respiratory drive is restored, no more. No violent pt, no puke to clean up, and yet at the same time I don't have to bag some body, I don't have to maintain their airway for them, they do it! And life is good, yes yes? I know there are providers who use it to punish people. That is wrong, I agree. But a proven safe, effective and simple drug in the hands of field EMS personnel is about as non traumatic, non invasive as it gets. Ok, maybe bagging is less invasive, but have any of you attempted to bag someone for 90 minutes, by yourself, in the back of an ambulance while stuck in a snowstorm? It would wear you down! Yet with Narcan, my pt was breathing by himself, and all I had to to was monitor him.
I often agree with Vene, but I simply cannot see the logic behind this argument. I really can't even see the true argument. Why in the case of a simple, cut and dried narcotic OD would you not use a simple, time tired and proven procedure to correct (temporarily I admit) the problem until the body can correct the problem itself?
It is part of the required curriculum of all EMS education. Everyone knows about it. It is taught as mandatory curriculum in medical school as well. Sorry, no super military knowledge here. I have actually treated an organophosphate poisoning. There is not enough atropine on the truck. If there is any hope, you need to get to someplace that has a lot more before you run out.
From the operations standpoint, the max dose of the atropine/2pam autoinjecotrs is 3, and you can bet your last dollar that I get my 3 before the patient gets any.
Gross misinformation. European EMS is considerably more advanced than US EMS. On par or with the physician units greater than AU/NZ
Not getting into as many accidents perhaps. It is certainly not because anyone has that large of saves of potentially fatal blunt force trauma.
Show me the proof. An actual scientific study, not an anecdote. Because most of the cardiac arrest meds don't. The ones that do under a very limited scope of circumstances.
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boingo
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Bagging a patient for an extended period of time isn't without risk also. When the patient vomits and aspirates his stomach contents and ends up in ARDS on a vent because someone had the bright idea to forgo a well studied low risk reversal agent who's doing harm now? Seriously, Narcan is the wrong tree to be barking up, it is well studied, safe, and used by lay-persons (junkies, EMT's and vocational school paramedics 
) on a daily basis without sequelae. Can you bag a patient until the opiate wears off? Sure, if you have nothing better to do, however I'm willing to bet there is a better way.
What about the cost? Where is the uproar amongst the fically conservative clinicians about the cost of this? Toronto tx's and releases these people without wasting resources in the ED. On one hand, we talk about the ability to treat and refer as a means of saving money, on the other is the suggestion that us retard ambulance drivers sx, bag and place airway adjuncts and take them to the wicked smart special people in the hospital.
Your pissing up the wrong tree, withholding Narcan in apneic opiate OD's is a FAIL, pick another tx to demonize.
) on a daily basis without sequelae. Can you bag a patient until the opiate wears off? Sure, if you have nothing better to do, however I'm willing to bet there is a better way. What about the cost? Where is the uproar amongst the fically conservative clinicians about the cost of this? Toronto tx's and releases these people without wasting resources in the ED. On one hand, we talk about the ability to treat and refer as a means of saving money, on the other is the suggestion that us retard ambulance drivers sx, bag and place airway adjuncts and take them to the wicked smart special people in the hospital.
Your pissing up the wrong tree, withholding Narcan in apneic opiate OD's is a FAIL, pick another tx to demonize.
Seizures, acute withdrawal, pulmonary edema, and agitation are all side effects of narcan. Some of which are fairly common.
I rarely find opiate OD's actually need ventilation, usually a little bit of gentle stimulation while monitoring ETCO2 and SpO2 is enough. As long as you ensure adequate oxygenation and ventilation the workloads really quite low.
As for my own feelings vs staying on someone's good side? I've given narcan one time on the last two years, and that was an interns call. My own feelings happen to closely mirror Veneficus's on this, we spend too much time and effort on "life saving" treatments that may not be life at all and not nearly enough on the palliative stuff that makes a real difference.
I rarely find opiate OD's actually need ventilation, usually a little bit of gentle stimulation while monitoring ETCO2 and SpO2 is enough. As long as you ensure adequate oxygenation and ventilation the workloads really quite low.
As for my own feelings vs staying on someone's good side? I've given narcan one time on the last two years, and that was an interns call. My own feelings happen to closely mirror Veneficus's on this, we spend too much time and effort on "life saving" treatments that may not be life at all and not nearly enough on the palliative stuff that makes a real difference.
boingo
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No need for an infusion, nebulization works too. I don't want to use my anectdotal experience, however seeing that I see opiate OD's almost daily, I will. The chronic opiate abuser here doesn't get admitted unless there is some other pathology, these folks get Narcan, perhaps nebulized Narcan, observation and discharge. The ones tx by there junkie pals don't get transported, however our agency tracks all suspected opiate OD's as well as self reported tx w/Narcan by other IVDAs' and have had no adverse outcomes. These finding have yet to be published, hopefully soon. My agency tracks trends of illness, including opiate abuse and is actively involved with the IVDA community, needle exchange and Narcan distribution among known users, so my experience isn't total BS.
boingo
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Your experience is much different than mine. My usual presentation is the cyanotic, pinpoint pupil IVDA who's near apneic with GCS 3. You can administer all the "knuckle Narcan" you like to no avail. There is no doubt you can oxygenate these people without administering a reversal agent, as a matter of fact, I love taking a new EMT-B and letting them manage the airway as we prepare to reverse the opiate, it is great real life experience using a BVM ( a skill that is usually poorly taught).
I gave Narcan twice today.
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