Treat and Release after Naloxone – Is it Safe?

NaloxoneOften in the prehospital setting, naloxone is administered by EMS (or possibly a bystander) to reverse respiratory and CNS depression from presumed opioid overdose. The patient then wakes up, and not uncommonly, refuses transport to the hospital. The question is: Is it safe to ‘treat and release?’ A hot-off-the-press article, just published in Prehospital Emergency Care, addresses this question.

What is known

The folks over at The EMJClub Emergency Medicine Podcast (Dr. Brian Cohn, @emjclub) published a great analysis of this topic back in 2014 with toxicology expert Dr. Evan Schwarz (@TheSchwarziee). They identified 4 studies that looked at this exact question.1–4 The studies varied in methodology, but all found similar results: The risk of death from recurrent opioid toxicity after naloxone administration was low, ranging from 0 to 0.13%.

U.S. Prehospital Studies

The general strategy employed was retrospective chart reviews of medical examiner and prehospital records looking for occurrences of death after refusal of transport. The U.S. studies were conducted in the cities of San Antonio, TX and San Diego, CA.1,3The upside here is that the EMS systems are similar to those in other parts of the country. The downside being that we don’t have centralized databases in most states and therefore patients could be missed if they presented to other counties within the state. No deaths were documented in either study.

Non-U.S. Prehospital Studies

Rudolph et al. published on their experience in Denmark.4 EMS there is a bit different in that physicians are present in the field to assess the patient and make transport decisions. Furthermore, there is a central database, meaning that patients were probably not missed if they presented elsewhere. In this study, they also included poison center records. Three patients out of 2,241 (0.13%) were identified as having rebound opioid toxicity that likely led to death.

A similar study in Helsinki found no life-threatening events during a 12-hour follow-up period in 71 patients who refused transport after naloxone.2

Emergency Department Study

Watson et al. took a different approach.5 Utilizing a chart review strategy, they aimed to determine the frequency of opioid toxicity recurrence after an initial response to naloxone in sequential adult ED patients. The authors found that up to 45% had recurrent toxicity. Despite being an ED-based study, the results are difficult to interpret. Only 2 of the patients with recurrence had respiratory depression documented and neither received more naloxone. Most of the patients were oral opioid overdoses, rather than heroin. One take home point that is probably applicable: recurrence was more frequent with long-acting opioids, though it also occurred with short-acting opioids including heroin and codeine.

 

Prehospital Emergency Care

A New 2016 Prehospital Study

Hot-off-the-press is a new prehospital study, published in Prehospital Emergency Care, also assessing the risk of administration of naloxone with subsequent refusal of care.6 The authors conducted a retrospective review of all patient encounters by the Los Angeles Fire Department during July 1, 2011-December 31, 2013. The Coroner’s records were reviewed to determine if a patient with the same or similar name had died within 24 hours, 30 days, or 6 months of the initial EMS encounter. Of the 205 subjects identified, one (0.49%) died within 24 hours of the initial EMS encounter. The cause of death was coronary artery disease and heroin use. Two additional subjects died within 30 days, but the cause of death was either unknown or unrelated in both cases.

Application to ED Clinical Practice

  1. If a patient who receives prehospital naloxone for opioid toxicity presents to the ED, it is worth observing them for at least an hour (longer dependent on the situation). Be sure that after the naloxone has worn off, s/he doesn’t have recurrent opioid toxicity. Only one of the studies evaluated ED patients and found a higher rate of recurrent toxicity compared to the prehospital studies. The primary outcome in the prehospital studies was death. We can monitor more closely in the ED and can provide resources including substance abuse referrals and take-home naloxone.
  2. The most common opioid in the earlier studies was heroin. A one-time naloxone dose is generally sufficient to reverse heroin with a limited threat of recurrent toxicity. However, the opioid epidemic has changed, such that heroin is only part of the current problem. Prescription medications, fentanyl, and other opioids can be longer acting than naloxone’s 45-60 minute duration of effect. The Levine study aimed to reevaluate the earlier data in light of the current times.6 Although they found a low rate of death in 205 patients, recurrent toxicity may have been missed by their inclusion criteria.
  3. The EMJClub Emergency Medicine Podcast summarizes the prehospital data nicely:

“The bulk of this data supports the ‘treat and release’ strategy adopted by many EMS systems, with the caveat that such a strategy be employed in select patients who have returned to baseline with stable vital signs and are capable of understanding the risks associated with discharge in the field. If patients want to go to the ED, this should still be encouraged as patients could be evaluated for drug related infectious diseases, as well as receive information about addiction treatment and other social services. Transporting the patient against their will, and holding them in the ED, is probably unnecessary and does not seem to be supported by available evidence. However if the patient took a longer-acting opioid such as methadone, it may be prudent to specifically warn them of possible risks associated with these agents as studies did not specifically look at the safety of a ‘treat and release’ strategy in patients exposed to long-acting opioids.”

 

1.
Vilke G, Sloane C, Smith A, Chan T. Assessment for deaths in out-of-hospital heroin overdose patients treated with naloxone who refuse transport. Acad Emerg Med. 2003;10(8):893-896.[PubMed]
2.
Boyd J, Kuisma M, Alaspää A, Vuori E, Repo J, Randell T. Recurrent opioid toxicity after pre-hospital care of presumed heroin overdose patients. Acta Anaesthesiol Scand. 2006;50(10):1266-1270.[PubMed]
3.
Wampler D, Molina D, McManus J, Laws P, Manifold C. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care. 2011;15(3):320-324.[PubMed]
4.
Rudolph S, Jehu G, Nielsen S, Nielsen K, Siersma V, Rasmussen L. Prehospital treatment of opioid overdose in Copenhagen–is it safe to discharge on-scene? Resuscitation. 2011;82(11):1414-1418.[PubMed]
5.
Watson W, Steele M, Muelleman R, Rush M. Opioid toxicity recurrence after an initial response to naloxone. J Toxicol Clin Toxicol. 1998;36(1-2):11-17.[PubMed]
6.
Levine M, Sanko S, Eckstein M. Assessing the Risk of Prehospital Administration of Naloxone with Subsequent Refusal of Care. Prehosp Emerg Care. March 2016:1-4.[PubMed]

Author information

Bryan D. Hayes, PharmD, FAACT

Bryan D. Hayes, PharmD, FAACT

Associate Editor, ALiEM
Creator and Lead Editor, CAPSULES series, ALiEMU
Clinical Pharmacist, EM and Toxicology, MGH

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ALiEM Bookclub: Beyond the ED – Recommendations by Dr. Louis Ling

“Words can be like X-rays if you use them properly — they’ll go through anything. You read and you’re pierced.”
― Aldous Huxley, Brave New World

Dr. Louis Ling is currently Professor of Emergency Medicine and the Senior Vice President for Hospital Accreditation at the Accreditation Council for Graduate Medical Education (ACGME), however he is probably best known as one of the founders of Academic Emergency Medicine. He practiced for over 30 years at Hennepin County Medical Center (HCMC) where he ran the program in medical toxicology and served as the Associate Dean for Graduate Medical Education as well as the Chief Medical Education Officer. He has laid the groundwork for much of what we do now by starting the journal Academic Emergency Medicine as well as helping to found the Council of Residency Directors (CORD).

Beyond his accomplishments, to talk to him is to talk to person who not only has the experience but both the willingness and ability to continue to think deeply. He continues to inspire many of us, not by his accomplishments but by his continued enthusiasm that he brings to the whatever he is working on. ALiEM is excited to have Dr. Louis Ling share his book recommendations in this edition of ALiEM Bookclub: Beyond the ED.

Louis Ling

Dr. Louis Ling 

How Doctors Think (2007) [Amazon Link]

41InCaqN-lL._SX331_BO1,204,203,200_One of my favorite books is “How Doctors Think” by Jerome Groopman 2007. I used to think that medical students arrived to residency as newbies and through some magical process, graduated three years later as remarkably good clinicians. What I realize now is this transformation was not just because they knew more facts, it was because they could make decisions.

The thesis of this book is that the process for making decisions is what separates a mediocre doctor from a master clinician. Dr. Groopman explains through a series of stories about patients and doctors, how physicians make decisions but still make mistakes. He quotes my hero, emergency physician Pat Croskerry, in his discussion about how experienced clinicians use their experience to recognize problems but how our emotions and biases can lead us astray. Chapter 3 are emergency medicine stories, chapter 4 about primary care, but there are many examples of how the best doctors who are try their hardest are still lead astray. This book reminds me how easy it is to get complacent and overconfident and how I should always be mindful of the assumptions that I make everyday when I am in the emergency department. It’s a book written for the public, but is much more enlightening for physicians.

The Tourist (2009) [Amazon Link]51zVgyqgL4L._SX272_BO1,204,203,200_

I have always liked spy novels. I am always impressed with how the heroes can figure their way out of dilemmas with minimal information and split second decisions. One of my favorites is by Olen Steinhauer, The Tourist (2009) not to be confused with the Johnny Depp and Angelina Jolie movie.  The hero bears no similarities with James Bond or Jason Bourne who are confident, defy death and rarely make a mistake. Owen’s protagonist is a burnt out undercover CIA spy, like a tourist whose is always visiting and with an always changing identity. He is just getting along trying to do his job while puzzling over situations and dilemmas without a clear answer. Along the way it becomes clear that being a spy is the least desirable and least sexy job in the world. I would also recommend The Cairo Affair which is equally convoluted and puzzling to the very end.

41jFVZL72YL._SX336_BO1,204,203,200_

When Breath Becomes Air (2016) [Amazon Link]

If you have a plane ride, you have enough time to read When Breath Becomes Air by Paul Kalanithi, 2016. The author is a neurosurgery resident who tells his story about being a resident and a patient. He is extremely well read and in college, considers the meaning of life through a writing career before realizing that he can best consider life through the lens of a physician. The first half of the book tells about his formation to adulthood and his life as a neurosurgery resident. It is a process that is familiar to all physicians. The insight comes from the story after his diagnosis of cancer and how he responds, with his parents and his wife and his doctors. He tries to balance his role as a patient and what he knows as a physician. Like the rest of us, he knows we are all going to die.  He just happens to know that he will be dying soon and he wants to make a difference as a physician in the short time that he has. Instead of quitting and laying on a beach, he finishes his residency and leaves behind a record of the process for us to ponder and apply to our own process of dying and living.

  • ALiEM bookclub covered When Breath Becomes Air April 2016 – [link]

The Innovator’s Prescription (2009) [Amazon Link]51njZ4GDR5L._SX325_BO1,204,203,200_

If you are a big thinker, you should read (or have already read) the 2009 book The Innovator’s Prescription by Clayton Christensen. The author is from the Harvard Business School and developed the notion of “disruptive technology” for the business world and now applies it to medicine. We are not talking about small incremental improvements but changes that can transform everything we do. He uses the example of how ATMs transformed banks, and Facebook transformed relationships.

Similarly, in medicine the Flexner Report, antibiotics, retail clinics, telemedicine, and the electronic health record have or are in the process of changing how we provide care. Similarly, in Emergency Medicine we can point to procedural sedation and point of care ultrasound as disruptive innovations. The author discusses the integration of health care systems, payment and reimbursement changes, the pharmaceutical industry and my favorite topic, the how the failing medical education system will be disrupted. On the last topic, the author suggests that physician assistants, nurse practitioners, and international medical graduates may be disruptive and that in-house medical schools by the largest integrated systems (predicting the Kaiser medical school in Pasadena, California) will out-innovate the current medical schools. He describes how Toyota uses competency based training to decrease variability and how medical schools should as well. This is a book on many CEO’s bookshelves and will provide insights into what is to come. I find this book even more interesting with seven years of hindsight.

 

Author information

Taku Taira, MD

Taku Taira, MD

Assistant Professor of Clinical Emergency Medicine
Associate Program Director
LAC + USC Emergency Medicine Residency

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I am Dr. Carl Alsup, Ultrasound Fellow: How I Stay Healthy in EM

Dr. Carl Alsup is an emergency physician and ultrasound fellow at Thomas Jefferson University. His loves for the outdoors keeps him active and fit. Despite being busy with academic commitments, Dr. Alsup maximizes his wellness by incorporating it into his daily routine. His attitude and strategies on maintaining mental wellness are refreshing, and are definitely worth checking out. Here is how he stays healthy in EM!

 

 

  • Name: Carl Alsup, MDcarl alsup
  • Location: Philadelphia, PA
  • Current job(s): Ultrasound fellow/clinical faculty, Thomas Jefferson University
  • One word that describes how you stay healthy: Balance
  • Primary behavior/activity for destressing: Exercise

What are the top 3 ways you keep healthy?

Rock climbing, running, and time with my wife and dog.

What’s your ideal workout?

Well, ideally, I would wake up at dawn, hike miles to a pristine lake, set up camp, have a great meal, wake up the next morning and climb some forbidding peak, then hike back down and jump in said lake. However, that’s a little cumbersome, so usually I run to the climbing gym, and that way I get in two forms of exercise at once. I also bike to work daily and run to or from work when I’m training for races.

Do you track your fitness? How?

I have used multiple different trackers, from the iphone in place tracker (under “health” icon), to Fitbit, to GPS. Currently I don’t keep track of my climbing although I get a little nutty if I don’t get out enough. I converted from Nike Plus to Strava for tracking my running. I find it more interactive and I’m able to train with friends that live in other cities for races.

How do you prepare for a night shift? How do you recover from one?

Ideally for the first night shift I would sleep in, get some work done that day, eat something moderately big, nap, then wake up, exercise, and go in.

In reality I treat my first night shift as a call night, and try to either sleep in or get a nap in beforehand. Subsequent nights I try to go to sleep immediately when I get home, and sleep in a darkened and quiet environment. The first night is the most important for setting my schedule.

How do you avoid getting “hangry” (angry due to hunger) on shift?

I’m a huge grazer. I eat a PB&J sandwich almost every day at work. I also have an apple, orange, or grapes. Every shift I have a big bag of trail mix or nuts that I eat in small portions during the shift. I find that big meals slow me down and take me off my game. If I bring in a meal I try to eat it in two portions. Realizing early that you are getting “hangry” is really important. Whenever I’m frustrated I run through the HALT mnemonic (Hungry, Angry, Lonely, Tired) and try to at least identify if not fix the source.

How do you ensure you are mentally in check?

My wife and dog keep that in order. No matter how many close calls or bad calls or bad interactions I’ve had at a shift, my dog doesn’t care; he just wants me to throw the Frisbee.

I think it’s important to have perspective when it comes to our job. Our profession is full of close encounters with life and death. However, our jobs are not our entire lives. My wife helps keep me grounded in things/life outside of work. It helps me realize that other people have important issues, trials and tribulations, and office politics and family relations may be another’s life and death. EM is full of moments that require us to be “totally on point”, so it’s important to have some “totally off” moments to counter-balance and ensure wellness in EM.

What are the biggest challenges you face in maintaining a longstanding career in EM? How do you address these challenges?

I think the biggest challenges are burn out from systemic factors. Our medical records, sepsis charting, fear of litigation, and all that extraneous stuff take us away from what we all went in to this for — to be with and help patients. I frame my interactions about tests with patients in their interest. I bring the ultrasound into the room and perform the workup while listening to the patients. I try to find something special in all my patients. I try to really listen to what they say (and what the nurses say, and what the family members say). I try to picture the patient as a family member and find a story for them to tell about their lives. I try to frame my interactions with consultants in the best interest of the patient, not in my differences with them.

I have a pressure relief valve (aka know my limits). I try to do the right thing by my patients but sometimes doing the right thing means saving my energy for the next fight. I have certain things I will absolutely never cave on, and certain things I will but only after a threshold is reached. When stuff in the department is really crazy, I realize I have limits and try to focus only on the very most important things.

After shift libations or any kind of hang outs, especially with staff to debrief and vent, are also an essential part of the mix.

When I have a really demoralizing shift, I go back and read my application to medical school. Hopeful and un-jaded Carl had a lot of important things to say, and I strive to get back to why I went into this in the first place.

Best advice you have received for maintaining health?

“Find balance, but realize that balance is personal.” – Dr. Deborah Diercks

“Be nice.” – Dr Joel Gernsheimer

Who would you love for us to track down to answer these questions?

Ian Julie
Mike Stone
Jimmy Willis

Author information

Zafrina Poonja

Zafrina Poonja

ALiEM Assistant Editor,
How I Stay Health in EM series
Emergency Medicine Resident
University of Saskatchewan

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Trick of the Trade: Ear Irrigation in the Emergency Department

Ear pediatricEar irrigation is an important tool for adult and pediatric patients in the Emergency Department (ED) with ENT complaints. Irrigation can be used to clear ear cerumen, visualize tough-to-see tympanic membranes, and remove foreign bodies. This may reduce the need for subspecialist care and improve the patient’s hearing and quality of life.1 Commercial electronic and mechanical devices are available for irrigation and have been studied. Moulton and Jones presented the improved efficacy of foreign body removal using an electric ear syringe in an (ED) population.2 In this trick of the trade, we present a low cost and effective way of  “ear-rigation” taught to us by one of our veteran nurses using easily available tools in the ED.

Trick of the Trade:

Syringe and angiocatheter ear irrigation setup

Equipment needed:

  1. 14 or 16 gauge cannula (needle removed and tip trimmed)
  2. 20 mL syringe
  3. Body temperature saline

 

ear irrigation 3

 

Steps: Remove the IV needle and cut the cannula tip to remove shorten angiocatheter length. Prepare a bottle or basin of saline at a physiological temperature. Connect the syringe to the cannula and irrigate as needed. Attempt to irrigate in all directions if trying to dislodge cerumen or foreign bodies. 

 

IMG_0553

 

Tips

  1. Consider using a kidney-shaped small emesis basin to catch the fluid as it drips out of the ear.
  2. It is important to have water slightly warm (at body temperature) as cool water causes vertigo/nystagmus, nausea, and possibly vomiting. This can be seen in this video as utilized in the caloric reflex test.3 (Remember COWS from med school? Cold/opposite, warm/same.)
  3. Pro tip: Also works well as a low cost water gun. Temperature of liquid in this scenario is provider-dependent.

Safety

This set up for irrigation has been evaluated in the literature. Kumar et al looked at the pressures generated using this technique in vitro and found it appropriate for use in patients without increased risk of tympanic membrane perforation.4 The pressures generated do not exceed the pressure needed to cause perforation.

Expert Peer Review

See the EPR below by Dr. Jonathan Bronner with his 3 additional clinical tips.

 


1.
Memel D, Langley C, Watkins C, Laue B, Birchall M, Bachmann M. Effectiveness of ear syringing in general practice: a randomised controlled trial and patients’ experiences. Br J Gen Pract. 2002;52(484):906-911.[PubMed]
2.
Jones I, Moulton C. Use of an electric ear syringe in the emergency department. J Accid Emerg Med. 1998;15(5):327-328.[PubMed]
3.
Chris N. Oculocephalic and oculovestibular reflexes. Life in the Fast Lane. http://lifeinthefastlane.com/ccc/oculocephalic-and-oculovestibular-reflexes/. Published 2008. Accessed August 10, 2016.
4.
Kumar S, Kumar M, Lesser T, Banhegyi G. Foreign bodies in the ear: a simple technique for removal analysed in vitro. Emerg Med J. 2005;22(4):266-268.[PubMed]

Author information

Chris Belcher

Chris Belcher

EM Resident
Department of Emergency Medicine
Captain, United States Air Force Reserve

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Diagnose on Sight: Case of a red, swollen neck

Ludwig's AnginaCase: A 78 year-old female with a past medical history of asthma and hypothyroidism presents with a three day history of sore throat and a two day history of a “lump” along the right side of her neck. The “lump” has now progressed to involve both sides of her anterior neck and is accompanied with erythema, tenderness to palpation, and swelling. In addition, the patient has developed a hoarse voice and odynophagia. The patient’s primary care physician referred her to an ENT specialist, who then referred the patient to the ED for urgent imaging due to the concern for a deep space neck infection. Triage vitals are remarkable for a heart rate of 118 beats per minute. She is otherwise normotensive and afebrile. On physical exam, slight crepitation in noted on the floor of the patient’s mouth. Of note, the patient also informs you of her penicillin allergy. Which of the following is the biggest risk factor for this particular disease process? 

Diagnose on Sight Poll

Answer

Master Clinician Bedside Pearls

Edward Klofas, MD 
Clinical Associate Professor of Emergency Medicine
Stanford University

 

1.
Candamourty R, Venkatachalam S, Babu M, Kumar G. Ludwig’s Angina – An emergency: A case report with literature review. J Nat Sci Biol Med. 2012;3(2):206-208.[PubMed]
2.
Barakate M, Jensen M, Hemli J, Graham A. Ludwig’s angina: report of a case and review of management issues. Ann Otol Rhinol Laryngol. 2001;110(5 Pt 1):453-456.[PubMed]
3.
Srirompotong S, Art-Smart T. Ludwig’s angina: a clinical review. Eur Arch Otorhinolaryngol. 2003;260(7):401-403.[PubMed]
4.
Boscolo-Rizzo P, Da M. Submandibular space infection: a potentially lethal infection. Int J Infect Dis. 2009;13(3):327-333.[PubMed]

Author information

Shyam Sivasankar, MD

Shyam Sivasankar, MD

PGY3 Emergency Medicine Resident
Stanford University - Kaiser
Emergency Medicine

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