SEERS

Opioid overdose response education

Question Type: Interventionhttps://volunteer.heart.org/apps/pico/Pages/PublicComment.aspx?q=891

Teaching the layperson to save lives is a wonderful idea. Unfortunately in Ontario, Canada a live human study CJPH 2013;104(3):e200-4 [cf ref. 26] is teaching chest compressions only, specific to opioid poisoning.

Sign of overdose from the training literature Quote

• Can’t wake the person up• Breathing is very slow, erratic or has stopped• Deep snoring or gurgling sounds• Fingernails or lips are blue or purple• Body is very limp• Pupils are very small

Protocol steps Quote

1) Shake at shoulders, Shout their name 2) Call 911 if unresponsive 3) Naloxone Inject 1 ampule (1cc. 0.4mg) of Naloxone into arm or leg muscle 4) Chest Compressions Push hard and fast on the centre of the chest 5) Is it working? If no improvement after 3-5 minutes, inject a 2nd ampule (1cc. 0.4mg) of Naloxone and continue with chest compressions until EMS arrives.

Training Power Point Slide 23 https://www.cpso.on.ca/uploadedFiles/members/Meth-conf-POINT-PP.pdf

Training Webinar Slide 31 http://www.instantpresenter.com/ohtn/E956D7808049

Training video http://www.youtube.com/watch?v=zlbkU5IK5Do

ILCOR 2010 Part 8.5 Drug Overdose and Poisoning http://www.resuscitationjournal.com/article/S0300-9572(10)00453-3/fulltext#sec2260

Consensus on science

“Evidence from studies assessing other endpoints (efficacy of naloxone), as well as animal studies, support the use of assisted ventilation before giving naloxone in opioid-poisoned patients with severe cardiopulmonary toxicity.”

Treatment recommendation

“There is insufficient clinical evidence to suggest any change to cardiac arrest resuscitation treatment algorithms for patients with cardiac arrest caused by opioids. In adults with severe cardiovascular toxicity caused by opioids, ventilation should be assisted using a bag-mask, followed by naloxone, and tracheal intubation if there is no response to naloxone.”

Comment

Unfortunately what is happening is many people are showing up in hospitals with complications from chest compressions only, they should never have received.

50,000+ poisonings a year in Ontario, mostly children.http://www.ontariopoisoncentre.com/ontariopoisoncentre/section.asp?s=Statistics&sID=79

Reference 26 CJPH 2013;104(3):e200-4 2010 American Heart Association Guidelines Part 12.7: Toxic Ingestionshttp://circ.ahajournals.org/content/122/18_suppl_3/S829.full#sec-80

Toxidromes

“Practically every sign and symptom observed in drug overdose [poisoning] can be produced by natural disease, and many clinical presentations associated with natural disease can be mimicked by some poison.“

Opioid Toxicity

“There are no data to support the use of specific antidotes in the setting of cardiac arrest due to opioid overdose. Resuscitation from cardiac arrest should follow standard BLS and ACLS algorithms.”

“In the patient with known or suspected opioid overdose with respiratory depression who is not in cardiac arrest, ventilation should be assisted by a bag mask, followed by administration of naloxone and placement of an advanced airway if there is no response to naloxone.”

Primum non nocere - First do no harm

Gary Thompsonjgary.thompson@mail.utoronto.caStudentDisclosures None

Response to Michael W. Dailey, MD "If death rates rise or fall, is it the distribution of training to users, the variability of heroin supply and nature of overdose?" We are having a rise in morbidity and mortality in Ontario, Canada of not only drug users but anyone else that suffers any respiratory emergency. Human study CJPH 2013;104(3):e200-4 chest compressions only specific to opioid OD.

Should Naloxone Be Available to All First Responders?http://www.jems.com/article/administration-and-leadership/should-naloxone-be-available-all-first-rMichael W. Dailey; A.J. Heightman MPA, EMT-P; Jeffery M. Goodloe MD

Quote “The only indication for naloxone administration in the prehospital setting by laypersons, police, EMTs or paramedics should be opioid-induced respiratory depression or respiratory arrest"

Jeffrey M. Goodloe, MD Drugs Falling into the Wrong Hands – or Not? Naloxone Use by Non-EMS Personnelhttp://roguemedic.com/2014/02/gathering-of-eagles-2014/What about the well documented opioid overdose mimics that paramedics have trouble with – stroke, hypoglycemia, seizures, et cetera

Response click comment boxhttp://roguemedic.com/2014/03/issues-and-challenges-discussed-by-medical-directors-at-eagles-conference-part-1/ Forgot to mention my friends are making themselves SICK teaching this.

Response to Emily Oliver (waiting for moderator)

"....use of naloxone into their education programs. More research is needed regarding educational effectiveness..."

Do we need more research on opioid poisoning resuscitation protocols? Clinicians see opioid poisoning daily in a clinical situation. Terminally ill are kept "comfortable" to wit OD narcotics. Cause of death acute respiratory failure.

European Resuscitation Council Guidelines for Resuscitation 2010 Section 8.b Poisoning http://resuscitation-guidelines.articleinmotion.com/article/S0300-9572(10)00441-7/aim/

Opioids

“Opioid poisoning causes respiratory depression followed by respiratory insufficiency or respiratory arrest. The respiratory effects of opioids are reversed rapidly by the opiate antagonist naloxone.”

Modifications for Advanced Life Support

“There are no studies supporting the use of naloxone once cardiac arrest associated with opioid toxicity has occurred. Cardiac arrest is usually secondary to a respiratory arrest and associated with severe brain hypoxia. Prognosis is poor.”

Agnotology is the study of culturally induced ignorance or doubt, particularly the publication of inaccurate or misleading scientific [medical] data. Agnotology focuses on the deliberate fomenting of ignorance or doubt in society.http://issuu.com/garythompson81/docs/agnotologynote.docx

http://youtu.be/JIztupsnjh0 CPR guidelines hyperlinked. EXPERT ADVISORS Dr. Peter Selby (Chief of Addictions CAMH); Deb Matthews; Kathleen Wynne & Dr. Eric Hoskins. No reply from politicians to date. CAMH admits Naloxone may not work, give rescue breaths, ASAP.

CBC Oct 16 2014 http://youtu.be/mNczD8YK4RE Dr. Selby you slipped up Quote ‘COMA’ Email from Dr. Selby pure medical fiction Toronto Metro Hall http://youtu.be/-f11Nif8RkU Deputation Board of Health https://youtu.be/jSEEZe5Vr2oBaby http://youtu.be/mSe2LUysxcgKitchener Waterloo Crime Prevention http://youtu.be/znjKdfYRCGc

NOT PLACING BLAME, CHANGE THIS PROTOCOL FOR THE WELL BEING OF ALL. STOP A WAR ON HUMANITY SAVE LIVES

Sanguen Health Waterloo 519-603-0223Toronto Public Health 416-392-0520