Should we use Narcan on all CPR calls?

[VentMonkey]

My point is opiate overdoses go into cardiac arrest primarily because of prolonged respiratory arrest. As part of the resuscitation attempt why would it not be appropriate to push narcan in addition to ACLS drugs. If the patient is an overdose and narcan is not started the patient is not going to be able to breath on their own, we all know or should know about patient outcomes in intubated patients.

Maybe you should read up on a medication before you try to make a logical argument about it.

This^^^. I think you're missing a key link here. In the respiratory arrested opiate OD who is found in cardiac arrest, you have to focus on the cardiac aspect above all else before worrying about giving or considering Narcan.

Did the opiate contribute to their death in this instance? Sure, will it "revive them" when they're that far gone? Hardly. Fine if you want to give increments of Narcan post resuscitation with good reason, but I stand by what I said, I'm not worried about that immediately into a cardiac arrest patient regardless of their initial cause.

Also, what's funny about it having side effects, even in the peri-arrested OD? Someone in agonizing pain regardless of their lifestyle choices is hardly "funny" IMO, and shows a lack of decency and humanity.

 

[DesertMedic66]

My point is opiate overdoses go into cardiac arrest primarily because of prolonged respiratory arrest. As part of the resuscitation attempt why would it not be appropriate to push narcan in addition to ACLS drugs. If the patient is an overdose and narcan is not started the patient is not going to be able to breath on their own, we all know or should know about patient outcomes in intubated patients.

Out here our protocols state we do not attempt an advanced airway until 4 rounds of 200 compression with Epi given 1 mg IV/IO are given every 200 compressions.

If the patient still has pulses and has decreased respiratory drive from narcotics then by all means Narcan away. If the patient is in full arrest they are no breathing and will not magically start breathing right after you push the Narcan. That is why we breath for our full arrests. I have never seen nor heard of any full arrest where Narcan was pushed and the patient suddenly got ROSC right after the medication was administered.

 

[ArizonaEMT]

CALEMT - "Because narcan isn't going to solve the problem of the heart not beating. It's a unnecessary drug to give. Where in the ALCS algorithm does it state to give narcan? Were in your H's and T's does it state to tread a OD?"

Well it's 2015 AHA ECC Guidelines

Read about it here:
h t t p : / / eccguidelines.heart.org/wp-content/themes/eccstaging/dompdf-master/pdffiles/part-10-special-circumstances-of-resuscitation.pdf

 

[DesertMedic66]

CALEMT - "Because narcan isn't going to solve the problem of the heart not beating. It's a unnecessary drug to give. Where in the ALCS algorithm does it state to give narcan? Were in your H's and T's does it state to tread a OD?"

Well it's 2015 AHA ECC Guidelines

Read about it here:
h t t p : / / eccguidelines.heart.org/wp-content/themes/eccstaging/dompdf-master/pdffiles/part-10-special-circumstances-of-resuscitation.pdf

If you yourself actually read it you would know you just helped our case. In that article it states "
While there is no evidence that administration of naloxone will help a patient in cardiac arrest, the provision of naloxone may help an unresponsive patient with severe respiratory depression who only appears to be in cardiac arrest (ie, it is difficult to determine if a pulse is present)". In that link it is saying it may be reasonable for lay people or non HCP BLS providers to admin Narcan because for them it may be hard to tell if the patient has a pulse or not...

 

[GMCmedic]

Were in your H's and T's does it state to tread a OD?

Toxins

But I agree

ETA: i see they specifically address this further in AHA. I dont think ive ever actually read an ACLS book

Sent from my SAMSUNG-SM-G920A using Tapatalk

 

[CALEMT]

Toxins

Granted it crossed my mind, but would you consider an opioid overdose to be a toxic environment within the body? Sure the respiratory depression can cause respiratory acidosis, but in the full arrest setting thats already being addressed with positive pressure ventilations. Even then you're at Hydrogen ion (acidosis) which if metabolically will be addressed with administration of sodium bicarbonate. I see no reason to give narcan during the arrest. If you get ROSC like I've previously stated, it will be beneficial in blocking the opiate receptors in the brain and will help with ventilation efforts. I'm not arguing, but merely showing my train of though with Toxins in the H's and T's.

 

[DesertMedic66]

Granted it crossed my mind, but would you consider an opioid overdose to be a toxic environment within the body? Sure the respiratory depression can cause respiratory acidosis, but in the full arrest setting thats already being addressed with positive pressure ventilations. Even then you're at Hydrogen ion (acidosis) which if metabolically will be addressed with administration of sodium bicarbonate. I see no reason to give narcan during the arrest. If you get ROSC like I've previously stated, it will be beneficial in blocking the opiate receptors in the brain and will help with ventilation efforts. I'm not arguing, but merely showing my train of though with Toxins in the H's and T's.

Normally with toxins they are talking about drugs such as a TCA overdose or BB or CB OD.

 

[GMCmedic]

Ive always considered OD as well when referring to toxins, but like you I dont give Narcan in codes either so its irrelevant.

Sent from my SAMSUNG-SM-G920A using Tapatalk

 

[ArizonaEMT]

The point is narcan is starting to be put into protocols for ECC. I am sure more studies will come later on this.

Good Points on Toxins....... we will see later if they consider this a nuerotoxin.

 

[VentMonkey]

The point is narcan is starting to be put into protocols for ECC. I am sure more studies will come later on this.

Good Points on Toxins....... we will see later if they consider this a nuerotoxin.

Heh?

 

[VentMonkey]

Where this thread has gone:

 

[DesertMedic66]

The point is narcan is starting to be put into protocols for ECC. I am sure more studies will come later on this.

Good Points on Toxins....... we will see later if they consider this a nuerotoxin.

They are putting it in as "reasonable" for lay people. Last I checked we are not lay people...

 

[cprted]

CALEMT - "Because narcan isn't going to solve the problem of the heart not beating. It's a unnecessary drug to give. Where in the ALCS algorithm does it state to give narcan? Were in your H's and T's does it state to tread a OD?"

Well it's 2015 AHA ECC Guidelines

Read about it here:
h t t p : / / eccguidelines.heart.org/wp-content/themes/eccstaging/dompdf-master/pdffiles/part-10-special-circumstances-of-resuscitation.pdf

Empiric administration of IM or IN naloxone to all unresponsive opioid-associated resuscitative emergency patients may be reasonable as an adjunct to standard first aid and non-HCP BLS protocols. Standard resuscitation procedures, including EMS activation, should not be delayed for naloxone administration.

Buddy, these are the Lay Rescuer guidelines, not the ACLS algorithms. That's why the algorithm has "Call 911" as part of the treatment. We don't expect the public to able able to accurately assess pulses, so we tell them if they don't seem to be breathing, start CPR, get an AED, call 911 (and possibly use a street narcan kit).

You've brought up treatable causes (Hs & Ts), which of those is the cause of arrest in an opiate OD? Hypoxia. What treatment do we have for hypoxia? Tubes and BVMs (while compressions and defibrillation is ongoing). Narcan does not reverse hypoxia in a patient who is in cardiac arrest.

 

[Carlos Danger]

I don't think there is currently any evidence to support the idea of using naloxone routinely in cardiac arrest, and I'm not aware of any movements towards doing so. However - and I'm kind of playing devil's advocate here, but kind of not - why not try it? What makes it such a bad idea?

If you really understand the pharmacodynamics of opioids and naloxone, then you know that there IS more going on during an opioid OD than just respiratory depression. Respiratory depression is what we focus on because the majority of the time that is the primary cause of the arrest, and it is easily reversible. But in very high doses or in polypharm OD's, there's more at work than just the opioid slowing their breathing down to the point that they arrest, and the naloxone antagonizing the mU and Kappa receptors to get them breathing again. That's just the highly simplified version.

Did you know that naloxone is an effective vasopressor and inotrope, and that those effects are due to naloxone's effects on multiple receptors and pathways? Did you know that naloxone has reversed OD's of alpha2 agonists and ACEI's? Did you know that it has been shown to improve the chances of converting to a shockable rhythm when given to (non-OD) cardiac arrests? Did you know that it prevented deterioration of lactate and blood pH in hemorrhaging dogs, effectively blunting one of the big physiologic sequela of the low-perfusion state?

My point is not that I think we should start giving narcan to every arrest. I guess what I'm saying is that we should perhaps be a little more open minded to the idea of trying something new in cardiac arrest, and a little less committed to the dogma instilled by our paramedic instructors. Especially considering how little evidence exists to support what we already do, and how little dismal resuscitation rates remain.

I'd love to see a good study done on naloxone in cardiac arrest. It's a safe enough drug (with arguably fewer negative effects than high doses of epi) and the physiology involved could support a pretty strong hypothesis that it might be helpful.

Also, I think if you aren't using naloxone in cardiac arrest when an opioid OD is the suspected cause, just because "ventilation is what they need", you lack some understanding of what goes on during these arrests. It might not matter with a simple OD, and no, it isn't going to start the heart on its own, but it could potentially cause some physiologic changes that make resuscitation more likely, especially if the OD is due to some of the really potent opioids or a polypharm situation.

 

[agregularguy]

Did you know that naloxone is an effective vasopressor and inotrope, and that those effects are due to naloxone's effects on multiple receptors and pathways? Did you know that naloxone has reversed OD's of alpha2 agonists and ACEI's? Did you know that it has been shown to improve the chances of converting to a shockable rhythm when given to (non-OD) cardiac arrests? Did you know that it prevented deterioration of lactate and blood pH in hemorrhaging dogs, effectively blunting one of the big physiologic sequela of the low-perfusion state?

Interested in reading more on the conversion of shockable rhythms in non-OD arrests. I hadn't heard of that at all. Where did you read that?

 

[StCEMT]

With an organized code, it's not like we don't have the time to give it at some point. I have to run it for at least 30 minutes anyway, I will eventually have a chance. Not that I think it will magically fix anything, but if ROSC is achieved then that is one thing I can cross of the list of things to worry about. By no means an immediate priority, but seems to be worth doing IMO.

 

[cprted]

Interested in reading more on the conversion of shockable rhythms in non-OD arrests. I hadn't heard of that at all. Where did you read that?

https://www.ncbi.nlm.nih.gov/pubmed/19913979

This is the one I'm aware of.

 

[Carlos Danger]

https://www.ncbi.nlm.nih.gov/pubmed/19913979

This is the one I'm aware of.

Yep. Small study, not overwhelmingly compelling by itself. But just one more reason why I think it should be looked at.

 

[Handsome Robb]

Wasn't there something recently about opioids being cardioprotective during cardiac arrest?

Edit: found it.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3757806/

Sent from my iPhone using Tapatalk

 

[Bullets]

Just as an aside, how many people are regularly slamming huge amounts of Narcan and having their patients wake up flailing and fighting? Do people still really do this?

I've used a lot of Narcan. I worked in Yakima Washington. I used a LOT of Narcan. And in my anecdotal experience, n=1, I have never, ever had an opiate overdose wake flailing and fighting. Normally, after a half milligram of Narcan, they're breathing and if they're starting to wake up, awfully apologetic and embarrassed.

Perhaps a bit more careful titration is in order?

So in NJ, BLS and PD protocol is 2mg IN. So guess what every single unconscious patient i go to gets from the cops before i arrive? 2mg IN Narcan. we have tried to teach them but it has been an uphill battle. Its probably 50% of my patients who come up agitated and combative.