Provision of medical care at sea

Academic Emergency Medicine

Objective: St. Paul's Early Discharge Rule was derived to determine which patients could be safely discharged from the emergency department after a 1-hour observation period following naloxone administration for opiate overdose. The rule suggested that patients could be safely discharged if they could mobilize as usual and had a normal oxygen saturation, respiratory rate, temperature, heart rate, and Glasgow Coma Scale score. Validation of the St. Paul's Early Discharge Rule is necessary to ensure that these criteria are appropriate to apply to patients presenting after an unintentional presumed opioid overdose in the context of emerging synthetic opioids and expanded naloxone access. Methods: In this prospective, observational validation study, emergency medicine providers assessed patients 1 hour after administration of prehospital naloxone. Unlike in the derivation study the threshold for normal oxygen saturation was set at 95% and patients were not immediately discharged after a normal 1-hour evaluation. Patients were judged to have a normal 1-hour evaluation if all six criteria of the rule were met. Patients were judged to have an adverse event (AE) if they had one or more of the preestablished AEs. Results: A total of 538 patients received at least one administration of prehospital naloxone, were transported to the study hospital, and had a 1-hour evaluation performed by a provider. AEs occurred in 82 (15.4%) patients. The rule exhibited a sensitivity of 84.1% (95% confidence interval [CI] = 76.2%-92.1%), a specificity of 62.1% (95% CI = 57.6%-66.5%), and a negative predictive value of 95.6% (95% CI = 93.3%-97.9%). Only one patient with a normal 1-hour evaluation subsequently received additional naloxone following a presumed heroin overdose. Conclusion: This rule may be used to risk stratify patients for early discharge following naloxone administration for suspected opioid overdose. O pioid-related emergency department (ED) visits continue to increase, with the number nearly doubling from 2005 to 2014. 1 Although opioid use disorder and its associated harms are not a new phenomenon, appropriate patient disposition after naloxone reversal of a presumed opioid overdose remains unclear. Some providers have advocated for a 4-to 6-hour observation period, but a recent

Prehospital emergency care : official journal of the National Association of EMS Physicians and the National Association of State EMS Directors, 2016

EMS providers frequently encounter opioid-toxic patients who receive naloxone and then refuse further medical care. Older studies revealed this practice to be safe. In light of the evolving patterns of opioid abuse, this study attempted to determine the safety of this practice. This is a retrospective review of all patient encounters by the Los Angeles Fire Department (LAFD) between July 1, 2011-December 31, 2013. All LAFD patient encounters are stored electronically. These electronic records were reviewed for subjects who received naloxone had a documented respiratory rate (RR) less than 12, and subsequently refused transport. Data abstracted included name, social security number (SSN), date of birth (DOB), date of EMS encounter, age, and treatment rendered. The names, SSN, and DOB, as available, were supplied to the coroner's office. The Coroner's records were reviewed to determine if a patient with the same or similar name (e.g., Jon vs. Jonathan) had died within 24 hours...

Clinical Toxicology, 1997

Postgraduate Medicine, 2016

Background: Naloxone is indicated for reversal of opioid-induced respiratory depression.

Anesthesiology, 2006

Background The objective of this investigation was to examine the ability of the opioid antagonist naloxone to reverse respiratory depression produced by the mu-opioid analgesic, buprenorphine, in healthy volunteers. The studies were designed in light of the claims that buprenorphine is relatively resistant to the effects of naloxone. Methods In a first attempt, the effect of an intravenous bolus dose of 0.8 mg naloxone was assessed on 0.2 mg buprenorphine-induced respiratory depression. Next, the effect of increasing naloxone doses (0.5-7 mg, given over 30 min) on 0.2 mg buprenorphine-induced respiratory depression was tested. Subsequently, continuous naloxone infusions were applied to reverse respiratory depression from 0.2 and 0.4 mg buprenorphine. All doses are per 70 kg. Respiration was measured against a background of constant increased end-tidal carbon dioxide concentration. Results An intravenous naloxone dose of 0.8 mg had no effect on respiratory depression from buprenorph...

Anesthesiology, 2009

PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints, and are not intended to replace local institutional policies. In addition, practice guidelines developed by the American Society of Anesthesiologists (ASA) are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data. This document updates the "Practice Guidelines for the Prevention, Detection and Management of Respiratory Depression Associated with Neuraxial Opioid Administration" adopted by ASA in 2007, and includes new survey data and recommendations pertaining to monitoring for respiratory depression.

Anesthesia & Analgesia, 2015

Background-To identify patient and procedural characteristics associated with postoperative respiratory depression or sedation that required naloxone intervention. Methods-We identified patients who received naloxone to reverse opioid-induced respiratory depression or sedation within 48 hours after discharge from anesthetic care (transfer from the post anesthesia care unit, or transfer from the operating room to postoperative areas) between July 1, 2008 and June 30, 2010. Patients were matched to two controls based on age, sex, and exact type of procedure performed during the same year. A chart review was performed to identify patient, anesthetic and surgical factors that may be associated with risk for intervention requiring naloxone. In addition, we identified all patients who developed adverse respiratory events [hypoventilation, apnea, oxyhemoglobin desaturation, pain/sedation mismatch] during Phase I anesthesia recovery. We performed conditional logistic regression taking into account the 1:2 matched set case-control study design to assess patient and procedural characteristics associated with naloxone use. Results-We identified 134 naloxone administrations, 58% within 12 hours of discharge from anesthesia care, with incidence of 1.6 per 1,000 (95% CI 1.3-1.9) anesthetics. Presence of obstructive sleep apnea (odds ratio = 2.45, 95%CI 1.27-4.66, P = 0.008), and diagnosis of adverse respiratory event in postanesthesia recovery room (odds ratio = 5.11, 95%CI 2.32-11.27, P < 0.001) were associated with increased risk for requiring naloxone to treat respiratory depression or sedation following discharge from anesthesia care. Following discharge from anesthesia care, patients administered naloxone used a greater median dose of opioids (10 [interquartile range 0, 47.1] vs. 5 [0, 24.8] intravenous morphine equivalents, P = 0.020) and more medications with sedating side effects (N = 41 [31%] vs. 24 [9%], P<0.001). Conclusion-Obstructive sleep apnea and adverse respiratory events in recovery room are harbingers of increased risk for respiratory depression or sedation requiring naloxone after discharge from anesthesia care. Also, patients administered naloxone received more opioids and Weingarten et al.

Journal of applied physiology (Bethesda, Md. : 1985), 2015

OPIOID-INDUCED RESPIRATORY depression (OIRD) is a serious public health and patient safety concern. In 2010, drug overdose was the leading cause of injury death in the United States (32), with 75% of these deaths involving opioid analgesics (2, 10). The problem is not limited to outpatients: severe respiratory depression and death occur even in hospitals using closedloop administration devices [patient controlled analgesia (PCA)] and continuous pulse oximetry (13, 18). This phenomenon has drawn the attention of the Joint Commission, which recently issued a Sentinel Alert (29). The incidence of postoperative OIRD is estimated to be 0.5-2% (4, 7, 31) but may be higher in certain patient populations and is almost certainly under recognized and under reported (6, 18, 27). There is clearly a need for greater understanding of risk factors for OIRD and development of monitoring techniques that can accurately and reliably detect respiratory depression. Prediction of patients at risk for OIRD is difficult and tends to be inaccurate. Some associations have been identified, including advanced age, American Society of Anesthesiologists (ASA) status Ն3, chronic opioid use, obesity, obstructive sleep apnea (OSA), chronic pulmonary disease, and coadministration of sedative drugs (3, 28, 30). However, although these factors are statistically associated with OIRD, they are often poorly predictive in individual patients. Moreover, OIRD occurs unpredictably in patients who are not considered "high risk." For example, in 102 consecutive opioid-related respiratory events at Duke Hospital, 50% occurred in patients younger than 60

2011

Background. The expanded suffocation false alarm theory (SFA) hypothesizes that dysfunction in endogenous opioidergic regulation increases sensitivity to CO 2 , separation distress and panic attacks. In panic disorder (PD) patients, both spontaneous clinical panics and lactate-induced panics markedly increase tidal volume (TV), whereas normals have a lesser effect, possibly due to their intact endogenous opioid system. We hypothesized that impairing the opioidergic system by naloxone could make normal controls parallel PD patients' response when lactate challenged. Whether actual separations and losses during childhood (childhood parental loss, CPL) affected naloxoneinduced respiratory contrasts was explored. Subjective panic-like symptoms were analyzed although pilot work indicated that the subjective aspect of anxious panic was not well modeled by this specific protocol.

USE OF NALOXONE FOR REVERSAL OF PICTURES OF OPIOID POISONING (Atena Editora), 2022

Introduction: The consumption of illegal substances is notably a global public health problem. From this, opioid intoxication is, for example, the main cause of drug-related deaths in Austria. In this sense, the administration of Naloxone appears as a tool to combat toxic situations triggered by the use of substances of an opioid nature, given its antagonistic effect on the receptors of this class. Goals: to analyze the effects of using Naloxone as an intervention tool in cases of opioid intoxication. Methods: This is an integrative literature review, in the PubMed database, based on the descriptors: “naloxone” and “opioid intoxication ” in the last five years. Seven scientific articles were selected, all written in English and carried out in humans, and articles that did not fit the goals of the present study were excluded. Results: Naloxone was a significant intervening agent in the absolute majority of cases of opioid intoxication. Select exceptions were observed in which patients required endotracheal intubation and mechanical ventilation due to respiratory failure relatively refractory to large doses of Naloxone. However, the use of opioid antagonist medication has been proven to be the safest and most efficient method of reversing intoxication, with great results even as a treatment for cases of alcohol dependence. Conclusion: the use of naloxone to reverse opioid intoxication conditions proved to be safe and efficient, but with some adverse effects when using high doses of this opioid receptor antagonist. It is concluded that the administration of naloxone, in adequate doses, is a useful tool in overdose or acute opioid intoxication.