A quick look at NALOXONE

Does Naloxone save lives? Does it help in cardiac arrest? Prehospital use of Naloxone is surrounded by misinformation. This week, we examine the history behind Naloxone as well as how it can provide benefit. One of the most common misconceptions is the Naloxone has some benefit in cardiac arrest. It does not. The Rogue Medic did an excellent write up of Naloxone in his blog (see Show Notes) years before, but it has not killed the mythos of Naloxone in cardiac arrest. My hope is that this episode may be enlightening to a few providers, who can then share the knowledge with their peers. But first, let’s put to rest the misconception of evidence for Naloxone in cardiac arrest. Many “Naloxone Apologists” will cite Saybolt, et al. as evidence of benefit, but fail to actually dig through the data. When we read through the “evidence” supplied in the study, it does not paint a picture that anyone could logically construe as providing benefit. But don’t take my word for it, here’s the very data from the study. Age & Gender Recorded response time Narrative Outcome 73 YOF Asystole→ventricular fibrillation 4 min. Found in asystole. Over 22 min received epinephrine 3× and atropine 3× without effect. Subsequently administered naloxone 2 mg followed by epinephrine 1×. Pronounced in ED 49 YOF PEA→sinus tachycardia 1 min. Found in asystole. Over 16 min received epinephrine 1× and atropine 1×. Rhythm changed to PEA (rate unknown). Naloxone 2 mg administered, rhythm changed to sinus tachycardia (118 bpm) Died in Hospital, Day 2. 37 YOM Asystole→accelerated junctional rhythm 1 min. Found in asystole. Received epinephrine 2× and atropine 2× over 8 min. Naloxone 2 mg administered followed immediately by epinephrine at which point EKG converted to accelerated junctional rhythm (60 bpm). Pronounced in ED 24 YOM Asystole→PEA 4 min. Found in ventricular fibrillation. Defibrillated at 200 J and converted to asystole. Administered epinephrine and atropine without rhythm change. Naloxone 2 mg administered, rhythm changed to PEA (rate unknown). Pronounced in ED 62 YOM PEA→ventricular fibrillation 6 min. Found in PEA (rate 40 s). Over 6 min, received epinephrine 1× and atropine 1×. Remained in PEA (rate 90). Received naloxone 2 mg and epinephrine 1× and rhythm change to ventricular fibrillation. Died in Hospital, Day 1. 47 YOF Asystole→PEA 3 min. Arrest witnessed by BLS with <1 min anoxic time. Found in asystole. Received epinephrine 1×, atropine 1×. No changes. Received naloxone 2 mg, epinephrine 1× and atropine 1× and spontaneous non-sustained 20–30s runs of idioventricular PEA (HR unknown) were noted. Pronounced in Field 23 YOM Asystole→ventricular tachycardia (pulseless) 7 min. Found in asystole. Received epinephrine 2× and atropine 2× over 16 min. Remained in asystole. Received naloxone 2 mg, dextrose 50% 25 g, epinephrine, atropine, and sodium bicarbonate 50 mEq over 7 min. Converted to pulseless ventricular tachycardia. Pronounced in ED 36 YOF Asystole→sinus tachycardia 2 min. Found in asystole. Received epinephrine 2× and atropine 2× over 13 min. Remained in asystole. Received naloxone 2 mg. Converted to sinus tachycardia (130 bpm) within 2 min. Died in Hospital, Day 11. 72 YOF Asystole→PEA 2 min. Arrest witnessed by ALS 2–3 min after arrival with <1 min anoxic time. Fluctuated between PEA, asystole, and ventricular fibrillation. Received epinephrine 8×, atropine 3×, sodium bicarbonate 50 mEq 2×, and calcium chloride 1 g over 32 min. Defibrillated at 360 J 2×. Stayed in asystole. Received naloxone 2 mg. Converted back to PEA (rate unknown). Pronounced in ED 66 YOM PEA→ventricular tachycardia (pulseless) 10 min. Found in PEA (rate 35). Received epinephrine 2× and atropine 1× over 10 min. Remained in PEA. Received naloxone 2 mg, epinephrine, and sodium bicarbonate 50 mEq over 6 min. Converted to pulseless ventricular tachycardia (rate 150). Pronounced in ED 22 YOM Asystole→PEA 2 min. Found in asystole. Received epinephrine 2×, atropine 2×, and naloxone 2 mg over 7 min. Remained in asystole. Received 2nd dose of naloxone 2 mg. Converted to PEA (rate unknown). Survived to Hospital Admission (unknown outcome) 24 YOF PEA→asystole 5 min. Found in PEA (rate unknown). Four minutes after ALS arrival, patient received epinephrine and converted to asystole. Over 9-min interval patient received epinephrine 2× and atropine 2× and rhythm converted to PEA (rate 70). Patient received naloxone 1 mg and rhythm converted back to asystole Pronounced in ED 45 YOM PEA→asystole 2 min. Found in PEA (rate 10–20). Over 2-min interval, patient received epinephrine 1× and atropine 1×. Remained in PEA. Patient administered naloxone 2 mg, epinephrine 1× and atropine 1×. Converted to asystole. Pronounced in ED 45 YOM Ventricular fibrillation→PEA 2 min. Found in PEA (rate 110) and received epinephrine 1×. Converted to ventricular fibrillation. Patient received naloxone 2 mg and converted back to PEA (rate 60). Pronounced in Field 43 YOF PEA→asystole 8 min. Found in asystole. Over 22 min received epinephrine 3×, atropine 2× and thiamine 100 mg. Converted to PEA. Over 3 min patient received epinephrine 1× and dextrose 50% 75 g without rhythm change. Patient received naloxone 10 mg, epinephrine 2×, and bicarbonate 50 mEq and converted back to asystole Unknown Outcome The above data has been reproduced in accordance with the provisions of 17 U.S. Code § 107 “Fair Use” for the purposes of criticism, comment, and non-commercial educational purposes. CORRECTION: In this episode, I erroneously refer to Naloxone as N-allylnoroxycodone. The correct name is N-allylnoroxymorphone. Show Notes Cover Photo by JGPhotography2000 Pasternak, G. (2013). The Opiate Receptors. Springer Science & Business Media. ISBN 978-1-60761-990-1. Rundlett Beyer, J., & Elliott, H. W. (1976). A comparative study of the analgesic and respiratory effects of N-allylnorcodeine (nalodeine), nalorphine, codeine and morphine. The Journal of pharmacology and experimental therapeutics, 2, 330–339. Jasinski, D. R., Martin, W. R., & Haertzen, C. A. (1967). The human pharmacology and abuse potential of N-allylnoroxymorphone (naloxone). The Journal of pharmacology and experimental therapeutics, 2, 420–426. Codd, E. E., Shank, R. P., Schupsky, J. J., & Raffa, R. B. (1995). Serotonin and norepinephrine uptake inhibiting activity of centrally acting analgesics: structural determinants and role in antinociception. The Journal of pharmacology and experimental therapeutics, 3, 1263–1270. Prichard, D., Norton, C., & Bharucha, A. E. (2016). Management of opioid-induced constipation. British journal of nursing (Mark Allen Publishing), 10, S4-S11. Buajordet, I., Naess, A. C., Jacobsen, D., & Brørs, O. (2004). Adverse events after naloxone treatment of episodes of suspected acute opioid overdose. European journal of emergency medicine : official journal of the European Society for Emergency Medicine, 1, 19–23. Narcan | Naloxone | The Opiate Antidote to Save a Life. (n.d.). Retrieved June 10, 2016 Vilke, G. M., Sloane, C., Smith, A. M., & Chan, T. C. (2003). Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 8, 893–896. Rogue Medic: The Myth that Narcan Reverses Cardiac Arrest. (2012, December 12). Retrieved June 10, 2016 Rogue Medic: Naloxone in cardiac arrest with suspected opioid overdoses. (2012, April 05). Retrieved June 10, 2016 Saybolt, M. D., Alter, S. M., Dos Santos, F., Calello, D. P., Rynn, K. O., Nelson, D. A., & Merlin, M. A. (2009). Naloxone in cardiac arrest with suspected opioid overdoses. Resuscitation, 1, 42–46 Osterwalder, J. J. (1996). Naloxone–for intoxications with intravenous heroin and heroin mixtures–harmless or hazardous? A prospective clinical study. Journal of toxicology. Clinical toxicology, 4, 409–416. Endoh, H., Taga, K., Yamakura, T., Sato, K., Watanabe, I., Fukuda, S., & Shimoji, K. (1999). Effects of naloxone and morphine on acute hypoxic survival in mice. Critical care medicine, 9, 1929–1933. A 00:0000:00 Podcast: Download (Duration: 24:30 — 34.5MB) Subscribe: Apple Podcasts | Android | Email | Google Play | RSS