EMS World

FEB 2019

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40 FEBRUARY 2019 | EMSWORLD.com OVERDOSE INTERVENTION heroin, and fentanyl. Some of the stud- ies utilized medical examiner records to determine whether a study patient subsequently perished but don't tell us if patients required additional medical inter ventions before or that did not result in death. A study in San Antonio documented 552 patients who received naloxone and refused transport. There were no report- ed deaths within the next 48 hours, but there were t wo deaths subsequently: one from an overdose four days later, the other from a gunshot wound. 6 A San Diego study looked at 998 patients who overdosed from heroin and refused transport after naloxone. There were no reported deaths within 12 hours. 7 Another California study, this one in Los Angeles, enrolled 205 participants. There was one reported death within 24 hours (attributed to coronar y arter y dis- ease) and two more within 30 days. One of those deaths was also attributed to coronar y arter y disease; the other cause was unknown. 8 Other studies in Finland, Nor way, and Denmark have also demon- strated that adverse outcomes were rare after opioid resuscitations that declined additional medical inter vention. 9–12 Conclusions Patients found unresponsive and revived with naloxone still require a full evalua- tion as well as a search for comorbidities. The risk of concomitant ingestions such as alcohol is common. The patient is at risk for aspiration, infection, rhabdomyolysis, and recurrent use of illicit substances. For a more complete list, see Figure 1. Of patients transported to the hospital, most can be observed for 1–2 hours and discharged, but a few will require a subsequent dose of naloxone due to recurrent respiratory depression. This is typically evident in the first hour. 13 If a patient refuses transpor t, they must be able to comprehend your agen- cy's refusal form. They should have a minimum Gla sgow Coma Scale score of 15, have normal vital signs, and be able to ambulate normally. If they are capable of all this, the overall short-term risk of death after refusing transport to the hospital is low. The risk of additional morbidity in this circumstance is unclear. The crew should make ever y attempt to convince the patient to accept transport to the hospital for a more complete evaluation and observation period to mitigate any risks that might not be immediately obvious. REFERENCES 1. Centers for Disease Control and Prevention. Drug Overdose Death Data, www.cdc.gov/drugoverdose/data/statedeaths.html. 2. Gertner AK, Domino ME, Davis CS. Do naloxone access laws increase outpatient naloxone prescriptions? Evidence from Medicaid. Drug Alcohol Depend, 2018 Sep 1; 190: 37–41. 3. Rzasa LR, Galinkin JL. Naloxone dosage for opioid reversal: Current evidence and clinical implications. Ther Adv Drug Saf, 2018 Jan; 9(1): 63–88. 4. McDermott C, Collins NC. Prehospital medication administration: A randomised study comparing intranasal and intravenous naloxone. Emerg Med Int, 2012; 2012: 476161. 5. Li K, Armenian P, Mason J, Grock A. Narcan or Nar-can't: Tips and tricks to safely reversing opioid toxicity. Ann Emerg Med, 2018 Jul; 72(1): 9–11. 6. Wampler DA, Molina DK, McManus J, et al. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care, 2011 Jul–Sep; 15(3): 320–4. 7. Vilke GM, Sloane C, Smith AM, Chan TC. Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport. Acad Emerg Med, 2003; 10(8): 893–6. 8. Levine M, Sanko S, Eckstein M. Assessing the risk of prehospital administration of naloxone with subsequent refusal of care. Prehosp Emerg Care, 2016; 20(5): 566–9. 9. Boyd JJ, Kuisma MJ, Alaspaa AO, et al. Recurrent opioid toxicity after pre-hospital care of presumed heroin overdose patients. Acta Anaesthesiol Scand, 2006 Nov; 50(10): 1,266–70. 10. Buajordet I, Naess AC, Jacobsen D, Brørs O. Adverse events after naloxone treatment of episodes of suspected acute opioid overdose. Eur J Emerg Med, 2004 Feb; 11(1): 19–23. 11. Heyerdahl F, Hovda KE, Bjornaas MA, et al. Pre-hospital treatment of acute poisonings in Oslo. BMC Emerg Med, 2008; 8: 15–23. 12. Rudolph SS, Jehu G, Nielsen SL, et al. Prehospital treatment of opioid overdose in Copenhagen—Is it safe to discharge on-scene? Resuscitation, 2011; 82(11): 1,414–8. 13. Scheuermeyer FX, DeWitt C, Christenson J, et al. Safety of a brief emergency department protocol for patients with presumed fentanyl overdose. Ann Emerg Med, 2018; 72(1): 1–8. ABOUT THE AUTHORS Mitchell D. Maulfair, DO, is medical director of the Department of Emergency Medicine at Winter Park Memorial Hospital in Winter Park, Fla. Alexis S. Dressler, BS, is an honors graduate from the University of Central Florida, where she earned a bachelor's degree in communication sciences and disorders with a concentration in health services administration. She aspires to pursue a career as a physician assistant and earn a doctor of medical science degree. The sudden effect of opiate withdrawal caused by naloxone is not benign. Photo: Hilary Gates Patients found unresponsive and revived with naloxone still require a full evaluation as well as a search for comorbidities.

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