Naloxone and Cardiac Arrest: new Scientific Paper from AHA

 In 2010, the American Heart Association wrote “naloxone has no role in the management of cardiac arrest.”  This came as a surprise to many medics who routinely gave naloxone to cardiac arrests patients suspected of opioid overdoses, and may come as a surprise to many medics who continue this practice.

The idea against using naloxone is fairly simple.  If the opioid overdose caused the cardiac arrest, the cause of death is hypoxia.  Naloxone can reverse apnea in patients who are still alive, but naloxone cannot undo a hypoxic death.  Patients in cardiac arrest from opioid overdoses need to get their hearts started with epinephrine, and they need to be ventilated.  All naloxone can do is put the patient in withdrawal should they be resuscitated with ACLS drugs.  What about ventilation?  That’s what ambu-bags are for.

In their new March 2021 paper, Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association, the AHA maintains this same position.  They write: “naloxone does not have a likely benefit in patients with confirmed CA who are receiving standard resuscitation, including assisted ventilation, and there are some reasons to suspect that this practice may cause harm by increasing cerebral metabolic demand at a time of hypoxemia and acidosis.”  They also write “If the patient is definitely pulseless and receiving standard resuscitation, including assisted ventilation, naloxone is unlikely to be beneficial. Because there is a theoretical basis for harm, standard resuscitation alone is indicated.”

Where the 2021 protocols differ from the 2010 is the distinction for lay people and for medical responders who are unable to determine if a patient is truly pulseless.  In these situations, the AHA says, and I agree, “Clearly, some patients present with respiratory arrest and faint or difficult-to-palpate pulses; these patients are likely to benefit from naloxone” and “Opioid antagonism… is always reasonable and should be delivered along with CPR when it is uncertain whether the patient is pulseless.”

Bottom Line:  Paramedics should not deliver naloxone to patients in cardiac arrest once they confirm with palpation and their monitor, a patient is in cardiac arrest. It will do no good, and may cause harm. Laypeople and BLS providers should deliver naloxone to patients whose pulses they cannot feel and who they have reason to believe might have pulses.  The benefits here outweigh the harms.

I am doing some research on this issue with Connecticut SWORD data base and can report that it is quite common for both lay people and first responders to do CPR and administer naloxone to patients, who are found to have pulses on paramedic arrival.  Failure to deliver naloxone to these patients on the grounds they were in cardiac arrest would definitely have been harmful.

I can also tell you as a street paramedic, I have found apneic and pulseless to my palpation patients who, on attachment to my monitor, were found in narrow complex tachycardias, and who responded well to an ambu-bag and naloxone.

Men With Guns

I was a new paramedic.  The senior medic briefed me.  They took two guys out of a basement apartment with high carbon monoxide readings after a dryer caught on fire.  Ones already on the way to the hospital for evaluation. Your patient is the guy over by the building door arguing with the police officer.  He wants to go back in his apartment to get some items, and the officer won’t let him.  Just then the man punched the officer in the jaw..  The officer threw the man against a car and put him in a headlock, and then handcuffed him.  Instead of bringing him over to us to be evaluated, the officer put him into a squad car.  “Asshole!” he shouted at the man.

“Do you think he’s an asshole or do you think maybe carbon monoxide is making him act like an asshole?” I said to the other medic.  “Shouldn’t we go over there and talk to him?”

The medic shrugged, and said, “You can’t argue with a man with a gun.”

The cop took him to the police station for booking and we cleared the scene “Patient item A (arrested).”

Hours later we both happened to be in the hospital EMS room when a supervisor came in and told us the man had become increasingly altered at the police station and was rushed to the hospital where they found critically high carbon monoxide levels in his blood.  “I’m glad it wasn’t my patient,” the senior medic said, without looking at me..  

I spent the week worrying that I was going to get a phone call telling me my medical control had been taken away and I was finished as a paramedic.  Fortunately, that call never came.

That was over twenty-five years ago and I was still learning my way..  The episode taught me two lessons.  Don’t rely on someone else to make the good decisions for you, and if you are there as a medic, you need to speak up on behalf of your patient, prisoner or not, asshole or not..

I am not saying that from that point on I always stood tall, but I was at least headed in the right direction.

Over my twenty-five plus years as a paramedic, I have had clashes with police officers regarding patient care, less so as the years have gone by and police departments have become progressive, and possibly I have learned a calm, assertive manner.

When I worked in a contract town, I was always getting called to evaluate prisoners for “jailitis.”  There was pressure for me to tell the prisoners they were fine and did not need to go to the hospital.  Sign here.  If I insisted on them going to the hospital, the police department (PD) would have to send an officer along and the officer would have to wait as long as the prisoner was there, or until an officer from the next shift arrived to relieve him.

The PD wanted to cover their liability by calling me so they could say they offered the prisoner medical help when asked, but they wanted me to shoulder the responsibility for the refusal of transport.  I played it straight forward.  If I thought the person was sick, I advised them to go to the hospital. If I thought they weren’t sick, I’d tell them what I believed, but always made clear if the patient requested to go to the hospital after my evaluation, I would fight for their right to be evaluated there.  It would be up to the PD to refuse.

I noticed sometimes the PD would wait till my shift was done and another (more pliant) medic was on to call for the prisoner evaluation.

I have also responded to scenes where the police were sitting on patients, and I have always done my best to make certain that the person being sat on could breathe and that if they were going to be restrained, it would be in the safest manner possible.  I prefer 10 mg of Versed to four point restraints and a spit shield.  I have said clearly, “This man needs to be evaluated at the hospital.”

The line the medic used that day-- “You can’t argue with a man with a gun”--I have heard many times over the years --medics explaining why they did not immediately treat a patient who needed care, or why an MVA victim was transported to jail instead of the hospital, only to later need an ambulance, or even a shooting victim was left to die because one of the officers wanted to tape the crime scene off to preserve evidence.

A lesser known line from the Hippocratic Oath goes like this:

“Into whatsoever houses I enter, I will enter to help the sick.”

Remember when you are on a scene, you are not just John Paramedic, you descend from Hippocrates and all who have held his faith.  We are advocates for our patients.  We stand up for them, bad or good, rich or poor, white or black, asshole or not.

You will have confrontations in this work. Stand tall.  It’s okay to argue with the people with guns.  They will respect you if you are professional and firm.