Epinephrine in Cardiac Arrest

 

The use of epinephrine in prehospital cardiac arrest showed no difference versus placebo in determining favorable neurological outcome according to a long awaited randomized controlled study published yesterday (July 18, 2018) in the New England Medical Journal.

The trial showed epinephrine produced a higher rate of survival at 30 days than placebo, but that was accompanied by almost twice the rate of severe neurological impairment.

Over 8,000 patients were enrolled in the randomized double-blind trial conducted in the United Kingdom between December of 2014 and October 2017.

The thirty day survival rate was 3.2% in the epinephrine group versus 2.4% in the placebo group. At hospital discharge 31% of the epinephrine survivors had severe neurological impairment versus 17.8% in the placebo group.

Paramedics needed to treat 112 patients with epinephrine in order to produce one extra survivor and that survivor was much more likely to have a poor neurological outcome than a placebo survivor.

The authors of an accompanying editorial speculate that while epinephrine may increase return of spontaneous circulation, it may also "result in long-term organ dysfunction or hypoperfusion of the heart and brain."

You can read the study and accompanying editorial at these links:

A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest

Testing Epinephrine for Out-of-Hospital Cardiac Arrest

 

Will this result change AHA ACLS guidelines?

We will have to wait and see. The AHA has been very reluctant in the past to make changes in the ACLS cardiac arrest epinephrine recommendation despite multiple trials showing no benefit or possible harm. Perhaps they will further temper their current recommendation.

Standard-dose epinephrine (1 mg every 3 to 5 minutes) may be reasonable for patients in cardiac arrest (Class IIb, LOE B-R).

What is next?

Look for studies using a decreased dose of epinephrine or studies targeting specific rhythms.  I have always thought it odd that we use the same 1 mg dose of epinephrine for an 80 year old 100 pound woman with a cardiac history who collapsed having an MI and for the thirty-nine year old 250 pound male with an opioid overdose.

In the meantime, what does this study mean for front line paramedics?

Focus on good CPR and timely defibrillation.  

Veins

 

Kelly is as dispirited as I have seen her. “My veins are shot,” she says. “I can’t even get high.” IV users use 1 cc syringes which have a very small needle they only need to slip inside the vein. When they pull back and get blood they know they are in. They push the plunger slowly, sending the heroin directly into their vein and right into their circulation where quickly delivers its powerful payload to the brain. This is a faster and stronger route than swallowing a pill or inhaling the powder in through the nose. If however, the needle in not anchored in the vein, the drug goes into the tissue where it can cause damage and necrosis. The user still gets an effect, but it is less strong and comes at a price in damage to the tissues.

Kelly has shown me her veins before and they are challenging. I fancy myself an expert at inserting intravenous lines. I may be an average medic in some skills, but I am really good at IVs. I have been doing IVs for twenty five years on all types and ages and races of people.
There is a difference between doing an IV as a paramedic and inserting a hypodermic needle as a drug user. A paramedic has to insert the needle into the vein, and then they have to slide a catheter over the needle and anchor it in the vein. 

One key is to find the best vein. The easiest vein is the AC in the crock of the elbow, but when this is not available, I look for the vein along the wrist or one of the many hand or firearm veins. Sometimes, I use a small needle. A 24 gauge is the smallest we use. The higher the number, the smaller the gauge. IV users typically use and go under the wrists or high up on the bicep for a superficial vein. I didn’t used to, but now I need to put on my reading glasses to see the smallest veins. I enjoy getting compliments from intravenous drug users who are my patients when I get IVs in after they tell me it is impossible. “Damn, you are good,” a woman says, and sends me a smile that makes my job worthwhile.

I don’t always use the arm. Sometimes I use the lower extremities. It is not an ideal place, but when an IV is needed, it will work. In extremis, I may also use the jugular vein in the neck. It is a large vein, but because it is deep, it requires a strong but sure touch to anchor the needle and not pierce the vein. Another difference between me and IV user is I get to practice on an endless variety of patients. An IV user is limited to their own body and to veins that they may hit too often. Some users -mechanics- may earn extra pay or free dope for injecting others. I think in another life, I would be good at this.

As part of my harm reduction efforts, I tell users how to inject safely. Rotate your veins I tell them. Clean them thoroughly before using. Ideally, with soap and water, but in a pinch an alcohol wipe will be better than nothing. Always use a fresh needle. Reusing a needle will blunt the needle and cause it to damage the vein. Never try to sharpen a used needle. Know where to get clean needles. I tell them where the needle exchange van is located. If they have money, they can also buy 10 clean needles for $3.99 at most pharmacies. Some bodegas will sell needles for $1-2. Sometimes other users who have gotten extra needles, by picking up dirty needles off the ground and exchanging them, will sell their extras for $1.  

I don't know how many of them follow my advice or let my advice get in the way of getting their next fix if they lack the soap and water, the clean needle or a dormant vein.  Users got to use, they say.

“Have you thought of trying your legs,” I say to Kelly. I ask this more to gage her reaction than to offer sage advice.

“No way, I’m not doing that. That’s bad for you. You can fuck your legs up.”

I am fascinated in her response. I am tempted to say you have no compunction about injecting a deadly drug cut with who knows what chemicals, but you don’t want to inject your legs. The legs veins are more likely to get infected and create clots that travel to your heart or brain or simply get stuck in your legs and cause swelling and tissue damage. But if your arms are shot, and you want to keep using IV, which as I have mentioned is the best bang for the rare buck, the legs are the next best alternative. The feet, the groin and the neck are all far more dangerous.

“I don’t get it,” I finally say to her, unable to hold it in.  “You’re putting heroin and god knows what chemicals it is mixed with in your body. You get a bad batch and you can easily overdose and die, but you won’t even consider, shooting up in your legs, even though you are desperate for a fresh vein.”

“No, it’s bad for you,” she says, completely without irony.

There are a lot of users limping along Park Street with abscesses in their feet.  Maybe she is feeling she needs to get around to get up her $4 to get her dope.  She isn't ready for that yet.

***

We are called for a woman hemorrhaging on the side of the road. We arrive to find her sitting against a fence. I recognize her as a heroin user I have seen on Park Street. She is sitting in a lake of blood. Her skin is cool, clammy and diaphoretic. Gloved up, we get her quickly on the stretcher and on the way to the hospital. Her pressure is 70/40. Her heart rate 135. She is in shock from blood loss, but we are having a hard time determining where it is coming from. Not her vagina or rectum. When we press against her abdomen on the right side, she screams in pain. Her lower right abdomen is hard and rigid. When I press, I see a spray of red blood come from a tiny hole in her groin.

She is an IV heroin user and she admits she shot up in her groin, trying to hit the femoral vein. The problem with injecting in the groin is it is a blind insertion; you can hit a nerve, go into tissue or puncture the femoral artery. I am guessing she either hit the artery and it is now bleeding into her, or continued use of the groin caused an abscess that ate into the wall of the artery. In either case, she is in shock from blood loss. We hold pressure on her groin and race her to the hospital, calling a medical alert, and we go right past triage to a resuscitation room, where a gowned team goes to work on her. She is up in the OR before we leave the hospital.

***

I think about Kelly and wonder what she will do. Her arm veins are shot. She works hard for her 4 dollars and if she can’t hit a vein, she isn’t getting $4 worth of hit out of her dope. And it’s not that she needs to hit the vein just once. Minimum four times a day she has to shoot up. Four times a day, every day for the rest of her life or at least until she decides to go clean. What must go through her mind as she searches for a vein? At one time did she balk at injecting in the first place? And what was it that caused her to finally crumble through that barrier?

I ask her about the first time she injected drugs and she says she was with her boyfriend Tom and two friends. They scored some Vicodin, but not having enough to go around, he crumbled it into power, squirted some saline into a spoon, and stirred it down to solution which he loaded into a syringe. He hit her first vein. Then they went ice-skating. In the winter time in Bushnell Park, the city erects a skating rink for residents of the city. You don’t need money to rent the skates they have. She tells me about skating on the ice in the park high on IV Vicodin. She describes it as if she were in a snow globe floating through the blue and white sky.

I think about the girl who punctured her femoral vein and nearly bled to death on a Hartford street. What was it like for her the first time she injected? How many years did she inject before she killed off her arm veins? Her leg veins? The veins between her toes? When did she first inject in her groin? What will happen to her when she gets out of the hospital? Will they get her into rehab? How many times has she been before? Does she believe she may be able to one day break free? Or is hope no longer a word she knows?

When the time comes for Kelly and for this other woman to die will they will be alone in misery and pain? Or will they ascend into the sky peaceful like snow globes in the clouded hands of their god, their days of suffering on earth vanished?

Pulmonary Edema in Opioid Overdose

 

She finds him in the bathroom at seven in the morning and knows immediately he is using heroin again. Three weeks ago, they moved east from Seattle. She had a job offer and it also represented a chance to get him away from his junky friends. After three times in rehab, she didn’t think she could go through it with him again so she was thrilled when he agreed to move with her. They got a nice loft downtown, with plenty of light. It was close to her job, and from across the street, he could get a city bus to any job in the area he could find. If was convenient to many things – a minor league ballpark, movie theatres, riverside park with running trails, a health club within blocks. He was always in good shape, but he particularly worked out hard when he was staying clean. Her new job was going to keep her busy, but there were plenty of restaurants they could go to at night, along with a comedy club and local brewpub. They’d make friends, and in time, if he started working and got a steady position, they could get up a down payment and move into the suburbs, start a family. Life had potential.

Now it seems like it is all back to where it was. She doesn’t even want to know where he got it or what drove him to it. She shakes him –hard and he wakes up and looks at her with a heart-breaking pathetic look that breaks her heart, more to see what it has done to him than any sense of betrayal to her. She knows how hard it is. Her brother, his best friend, died of an OD. She thought maybe if she couldn’t save her brother, she might be able to save him.

He is breathing well enough that she doesn’t call 911. She wishes for a moment she had gotten Narcan, but thinks that might have shown bad faith in him. She watches him and positions him so he won’t close off his airway. He mumbles he is sorry. She tells him she has to go to work. They can talk tonight. She kisses him on the forehead. “It’ll be allright,” she says. “We’ll make a plan tonight.”

“It was just one time,” he says. “I’m sorry. I fucked up.”

“I know.”

Still she checks the bedroom, looks in his jacket pockets, and in the bureau.  She finds nothing. It was just one time, she tells herself.

He is still on the couch when she comes back at lunchtime to check on him. She can hear him snoring, but his breathing sounds raspy. She shakes him and he looks at her, but his face has a bluish tinge and there is pink froth on his shirt and on the couch pillows. She picks up the phone and dials 911.

***

EMS arrives, and because the man can be stimulated they don’t immediately take out their Naloxone.  He is breathing and even capable of some words, but they don’t like the man’s color. His SAT is in the 70’s. His ETCO2 is 69. They put him on a nonbreather and listen to his lungs. Rales.
With the nonrebreather, they get his SAT up to 90%. Since it is likely noncardiogenic pulmonary edema, they hold off on the nitro.  He isn't alert enough for CPAP, so they given him 0.1 mg Naloxone IV and then a second 0.1 mg.  He is more alert and can take the CPAP.  His SAT remains on the 90% line.  In the ED, he is switched to Bipap. He is admitted to the ICU, where he gradually shows improvement. He is discharged home two days later. On the advice of the paramedics, his girlfriend now has Naloxone in the medicine cabinet.  While his lungs have recovered from their damage, his fight against opioids will likely continue for the rest of his life.

***

Pulmonary Edema is a known, but rare side effect of opioid overdose that can occur independently in opioid overdose or may be exacerbated by naloxone administration.

There is an excellent case study and discussion in the January 7, 2018 article that appears on the Emergency Physicians Monthly web site.

Dyspnea After a Heroin Overdose

Additionally there is another fine article published on September 1, 2017 in Fire Engineering Weekly.

Pulmonary Edema Following Opioid Overdose

While I recommend reading these articles, as well as some of the other journal articles they reference, here are some key points about pulmonary edema and opioid overdose:

It was first documented in 1880 by the famed physician William Osler.

No one is really sure what causes it, but some of the theories revolve around lungs damaged by hypoxia or by the pressure of trying to breath against a closed glottis, resulting in damaged leaky capillaries. It may also be caused or exacerbated by increased sympathetic response.
The prevalence of pulmonary edema in opioid overdose is estimated between 0.8 and 2.4%.

One study found that 100% of overdose fatalities were found on autopsy to have had pulmonary edema.

Deceased opioid overdose patients often present with a foam cone on their mouths typical of death from pulmonary edema. I have seen this on several occasions.

Pulmonary edema can develop up to an hour after a patient has been revived.

There seems to be some dispute over whether or not nitro is of use. One article says it is not because the pulmonary edema is not due to fluid overload. The other suggests it is effective.

Rapid administration of naloxone may worsen the edema by increasing the body’s sympathetic response.

Pulmonary edema in opioid overdose is generally classified as noncardiogenic pulmonary edema, but it can coexist with cardiogenic pulmonary edema.

Noncardiogenic pulmonary edema can development immediately after reversal with naloxone or it can develop up to four hours later.

The takeaway for EMS is to observe overdose patients for shortness of breath and hypoxia post resuscitation. A patient revived with naloxone may be alert and oriented, but if their SAT remains low, they may be in pulmonary edema or at risk for developing pulmonary edema.

Slipping Out

The man is trembling, sitting on the bed in the spare motel room down by the highway. Sometimes, these rooms are filled with the patient’s worldly belongings, but this room seems to only have the bed, a dresser, a chair and the TV. The man is in his late fifties, a portly man with white hair and liver spots on his hands. The Spanish woman in the room with him is of an indeterminate age. She wears a pink tank top and grey yoga pants with flip flops, even though it is cold and blustery out. She is the one who called. When I say she is of indeterminate age, I mean she could be anywhere from 30-50. It appears she is missing a fair number of teeth and her arms lack the tone of a younger woman. While he talks to us, she walks behind him and mimics a man shooting heroin. He says he is a diabetic and hasn't eaten or taken his insulin for a couple days. He says he got robbed last night and has no money. He is going to have some funds transferred up to him tomorrow. We check his sugar and it is 485. The normal range is 80-120. 485 is in the danger zone. If he doesn't take insulin soon, he could develop diabetic ketoacidosis and go into a coma. He wants to refuse, but we keep trying to persuade him to go. "No, no, I'm fine," he says.  "I'll get some insulin tomorrow. I'm fine, really."

He doesn't look fine. “Listen, I say. "Look around this room. Do you want to die in this room? You have a couple hours and then your mind is going to get really fuzzy. You may fall asleep. In your sleep you'll lapse into a coma and we'll be here in the morning except you'll be long gone, only your body will be here. If the nice lady here is with you, she may notice you are awfully cold, and we wouldn't her to have to go through that would we?"

"You gotta go honey. I'll pay for your insulin," the woman says.  "We have to take care of you."

His eyes blink and he looks from side to side.   "Okay," he says, "I'll go."

Outside the room as we walk him to the stretcher, the woman tugs my sleeve and says something about his name. I take out a pen and pad and am prepared for her to tell me to his name and date of birth. "No, no,” she says. "I need to know what his name is.  I just met him yesterday. They won't let me see him at the hospital unless I know his name."

Okay then.; I get his name for her.; She thanks me and says she'll be down in a little while. She sticks her head in the back of the ambulance before we shut the door and says, "Tell them, I'm your granddaughter."

Granddaughter, I am thinking, with the miles on her face she could easily have been his wife.

On the way to the hospital, I put in an IV line and start running in fluid. He finally admits to me that he did 20 bags of heroin last night. He says his wife threw him out of his home and he has been living in the hotel for the last week. I asked him how he got robbed, but he doesn't want to talk about it. I tell him he needs to have narcan with him if he is going to use heroin. I explain where he can get it. I give the whole rap about not using alone and doing tester shots.

When we get him in his ED room, he is very thankful to us. He makes eye contact as he shakes our hands.  I can tell he is worried about his physical shape.

"They'll take good care of you here," I say.

At the triage desk, I tell nurse the story. I think about leaving out the part about the heroin, but I don't.

"I thought he was in alcohol withdrawal at first," I say, “but he denied it. Of course, he also denied drug use, but then copped to doing 20 bags last night."

"Winner," she says, while typing her notes in the computer, all the while on hold with the ICU about a patient she is trying to get transferred up there.

The next Sunday I am working with a different EMT as my partner is out. We are talking about the heroin epidemic and he tells me he did a presumption at the same motel by the highway on Saturday afternoon. Late 50ish man, just released from the hospital. Cops found a syringe and were treating it like a crime scene. They didn't find any heroin bags -- they said it looked like the room aside from the syringe which they found under the bed, had been cleaned before they got there. The man's wallet was empty. I queried about the room and the patient and it was the same man.

My partner mentions the patient was in an odd position. Found on the ground in a praying position against the bed.

I tell him that this actually is a common position for opioid overdose deaths to be found in.

A couple years back I did a call that really disturbed me. At eleven in the morning at a motel in town, a maid finds the door unlocked and goes in the room and screams. We arrive to find a naked man on the floor, his butt up in the air facing us. He is riggored cold, resting on all fours, stiff as can be, his head turned to the side.

On the table by the bed stand is a mobile phone that is vibrating. I look at it. Full of messages. "Honey are you okay? Honey when are you coming home? Is everything alright. I am worried."

My partners and I discuss our theories of how he may have died. Based on other evidence in the room, we speculate that he might have been having anal sex when he either suffocated or his neck snapped. We guess his partner at some point noticed he was dead and fled the scene without calling anyone; I run my six second strip of asystole. Presume him dead.

I kept expecting to see a report of the murder in the paper but there was nothing. The security footage from the hotel ought to have captured who was there with him. How could anyone leave another human being like that? I read nothing in the papers.

Several years later, I am attending a seminar on fentanyl and I find myself looking at a slide of a dead man's bottom up in the air.

The very same man.

I learn that he died of an opioid overdose. And that this praying frog position is a common one when people collapse from opioid overdose. We are shown eight more photos of dead people in similar positions, all are opioid deaths.

I try to picture now the man we took to the hospital with the high blood sugar. He gets his insulin, gets a wire transfer from his bank, and goes back to the hotel with the woman of indeterminate age. Either she or he buys the heroin. A half a stack. Party time. They shoot up, the only problem is the bags of heroin are not heroin, but fentanyl; One of the bags contains a hotspot, a clump of fentanyl. He injects and a moment later his breathing slowing, he goes dark and slowly slumps forward to his knees, his arms out before him.

When his friend awakes from her prolonged nod, she sees him there. She gives him a little shake, but he is already gone. She knows this because this is not the first man she has been with who has had heroin issues. She carefully takes the remaining bags of heroin, any paraphernalia, and then slips his wallet out of his pocket, takes the remaining green and puts the wallet back. She lets herself out into the night.

I wonder if she remembers his name.

I wonder how many other people are out there who have been in similar situations, finding; a companion dead, and then robbing them and slipping out the door.

It is a brutal world.

Diploma

 

The man is on the nod, the only thing keeping him up is the fence he is leaning against. When the police officer tries to extricate him from the fence, he falls back and the officer has to lower him to the ground. I set my red bag down to get out my ambu-bag, but I can see the man is still breathing regularly. I shake his shoulder. He opens his eyes. No need to get out the Naloxone. I lift him up under his arms, while my partner grabs his legs. We get him on the stretcher. He nods back out. We find an orange capped syringe in his left front pocket, and some white powdered residue in a small plastic baggie in the right front pocket. The officer gets the man’s ID out of the wallet he finds in the man’s back pocket. He says he’s going to run his name for warrants.

We wheel the patient over to the ambulance and load him in the back. He is SATing at 97% and his ETCO2 is 48. The ETCO2 slowly climbs into the 50’s as he starts to hypoventilate, but with a little shake, I stimulate him enough to get it back down into the 40’s. While waiting for the officer to return with the man’s ID, I look through the backpack for medical information. There is an embossed certificate for successful completion of a 30 day residential treatment program with the man’s name on it, and an accompanying letter that attests to his meeting all the demands. There is a sheet of paper with his medical history which simply lists broken bones. There is an empty prescription vial for Suboxone. 42 count. Take three strips once a day. I count the days from his release from his treatment program when the prescription was filled until today. He ran out yesterday.

The officer comes back and says he got a hit on the warrants. He takes out his cuffs, and I look at him with a look that says, “Really?”

He says you never know with these people. He has to at least put something on. He cuffs one wrist to the stretcher. The man doesn’t even notice he is being cuffed. I don’t really blame the cop. We all have procedures we have to follow that don’t always seem to make the most sense. Once I did a transport out of a correctional facility for a man with no legs. They still had to put the chains on.

I monitor the patient’s breathing on the way to the hospital. I like talking to my opioid patients to learn their stories, but there is no conversation between us. He is too much on the nod to talk, but still ventilating well enough to not get Naloxone. I’d like to know more about how he came to be leaning against that fence, to hear his story of how he became a statistic in this great opioid war. The only things I know about him are he has suffered broken bones, he graduated from a 30 day treatment program, he was proud enough of himself that he kept his diploma, he appears to have been on Suboxone for 17 days, and then this morning, he injected heroin, and while it wasn’t enough to stop his breathing, it was enough to incapacitate him against a fence. When he comes out of his high, he is going to jail. 30 days or 90 days or a year or however long he’ll be locked up for, he’ll get out and have to start all over again.

I hope he can find a better support system than he had this time.