A Story Of War
The year is 1954 and war is raging in Vietnam. The French government is tired of the prolonged battles. General Henri Navarre was leading the French troops at this time. The Europeans and Americans all felt that the Vietnamese were untrained, unintelligent fighters who had not been prepared for battle like they had. General Võ Nguyên Giáp led the Vietnamese at this time, and the French considered him uneducated in proper 'textbook' warfare. It is true that the Vietnamese were not trained like the Europeans or Americans at all. The Vietnamese may not have gone through similar training, but they sure knew how to fight in their own country (especially after successful defense of their homeland against the Japanese in WWII). General Navarre wanted to bring this war in Vietnam to an end quickly, so against the wishes of the French government he staged an all out attack (forcing Giáp to attack) at a place called Dien Bien Phu. This was a grave mistake on the part of Navarre. Why?
Dien Bien Phu was surrounded by high ground (see opening picture). Between ten and fifteen thousand French troops marched into Dien Bien Phu, and were quickly surrounded by superior numbers of Vietnamese soldiers far above them. General Giáp had learned valuable lessons from past battles and now was much smarter about how to fight the French. The battle raged from March to May. The Vietnamese used superior position, fighting style, and planning to win this important battle - a true turning point in the war for an independent Vietnam. General Navarre lost because of poor planning, arrogance, and above all, underestimating his enemy. What could have changed the tides of war?
Navarre believed he could walk into the low ground, with poor supply chains, less men, no clue what the Vietnamese would do, and still win! How arrogant! If Navarre would have only respected Giáp as a formidable opponent, perhaps things would have turned out differently. Perhaps Navarre would have chosen a better position, a better deployment strategy, or a better route of battle. Instead, his arrogance, ignorance, and poor planning got his men slaughtered.
“There is no greater danger than underestimating your opponent.” ― Lao Tzu
Our Story Of War
Our story of war is not too different than the confrontation between Giáp and Navarre. How so? We fight an overdose war, but at its core, it is a battle against respiratory failure. Will we make the same mistakes as General Navarre?
Are we going into the respiratory failure battle with the right mindset?
General Navarre went in to Dien Bien Phu believing he could overpower a force he thought he understood - even if he was at a disadvantage. This is a true case of 'if you fail to plan, plan to fail.' In our case, we have to enter the battle with the mindset that it will take absolutely every tool in our toolbox, and every bit of our training to overcome this enemy. That may include:
Suctioning
Positioning the patient to maximize the functional residual capacity
Utilizing a sniffing position
Simple airway placement
BVM with PEEP and Oxygen or NPPV with a ventilator
High flow nasal cannula
Naloxone administration
Resuscitation sequence Intubation
Advanced ventilator management
We should not go into a suspected overdose believing that one intervention will save our patient. This is setting ourselves up for failure. I had two doctors message me after by last naloxone blog and their stories really stuck out to me because of how similar they were.
Story #1
Paramedics brought in a patient who was 'blue' and barely breathing - they did not give naloxone. After 2mg of naloxone, the patient improved.
Story #2
Paramedics brought in a patient who was 'blue' and barely breathing - they had given 14mg of naloxone prehospital. The patient of course had a brain bleed.
Someone may look at those two stories and think... those are not similar in the least. But really, they are exactly the same. In both cases, the paramedics failed to enter the call with the mindset that absolutely everything might have to be done to stabilize that airway and breathing. In both cases, they failed.
Diagnostic Inertia
I wish I could give credit to where I first heard the saying "diagnostic inertia." Once I was made aware of this common condition that plagues clinicians, it becomes so apparent everywhere you look. Here is how it works... You go in for a patient with a history of drug use. They are minimally responsive, there is some evidence of drug use on scene, and law enforcement is on scene administering naloxone prior to your arrival. Your brain is completely set up for believing this is an overdose. 'An object in motion will stay in motion until acted upon by an outside force.' Your diagnostic brain will continue on this 'overdose' course of thinking unless something starts to shift it in another direction.
As illustrated here, you might get drawn towards a certain diagnosis (which may be right or wrong) if you allow diagnostic inertia to take you over. It is like a magnet that draws you away from critical thinking. This can be rather dangerous in the case of suspected overdose. If we are not oxygenating, ventilating, and in general resuscitating before moving straight to naloxone, we might be betting brain cells on the wrong horse.
Take the patient above for example. Someone may think... '30 y/o males are in the high likelihood age range for heroin abuse, he's unresponsive, and his friends admit that he does drugs. Let's give him some naloxone and see how he does.' This would be a poor choice, if it's your only and first plan. If you dug a little deeper, you would know that they all went snowboarding last night. "Did he take any bad spills?" "Did he wear a helmet last night? "Was he acting strange after his wipeout?" Answers to these questions might greatly change your list of differential diagnosis possibilities. Of course other great questions would be:
Is he diabetic? (check the BGL)
Does he have a seizure history? (check his pupils and ETCO2)
Did you guys notice if he drank a lot last night? (is it ETOH poisoning?)
Has he ever had a bad allergic reaction to something? Do you know if he usually carries an EPI pen?
Has he complained of feeling sick or has he been in the hospital? (check his temp)
By managing life threats FIRST - oxygenating, ventilating, and resuscitating in general, you avoid making this grave mistake and missing the brain bleed he currently has going on. Some providers may choose to give small amounts of naloxone to attempt to rule out overdose, some may choose to fully protect the airway and not give naloxone. Have a wide range of differential diagnosis possibilities! This is a key element of what separates a very poor clinician from an excellent one.
A failed Paradigm?
Many people will say that they have used naloxone without issue. There is no shortage of the clinicians who like to tote their claimed experience in a 'very high overdose area.' Such anecdotal experiences of a select group really does not amount to much. They may consider a successful reversal just someone who eventually came around and started talking. Consider the issues we really do not have an answer to:
How many times is there emesis in the airway when we administer naloxone?
How many of those patients suffer from pneumonia later?
How many of those patients die?
Should we be visually inspecting the airway and suctioning before giving naloxone?
How many times are we giving naloxone for non-overdose related causes - causing delay in airway management and perhaps brain injury or death?
How many actual overdose patients have died or suffered brain damage because of sole reliance on naloxone by a clinician that did not work?
How much pain and trauma are we causing our patient by overshooting our dose of naloxone?
Will sign-off naloxone recipients become sicker later with the stronger doses of drugs we are seeing on the streets?
We simply do not have answers to these questions right now, and few people are likely thinking about them. After my last blog I had one doctor message me, stating the he has been trying to get funding to answer questions like these. He has not had any success in receiving funding as of yet. Good luck finding a study that looks at the negative effects of the way we currently manage overdoses... The vast majority of the world is still in the honeymoon phase with naloxone - especially in light of the ever increasing opioid epidemic. Some studies have looked at ALI and pneumonia after opioids, but they do not really answer the answers begged here.
https://www.ncbi.nlm.nih.gov/pubmed/20642252
https://www.reuters.com/article/us-health-overdose-trend/opioid-overdoses-leading-to-more-icu-admissions-and-deaths-idUSKCN1AW2KA
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3324739/
A New Paradigm
Many do not believe the standard of care for an overdose patient should be delivering them to the ED barely breathing with a questionable airway and questionable airway reflexes. You will usually hear clinicians say 'I always just reverse to a RR of 8..' I have never personally seen or heard of this actually happening. Should this really even be our goal?
Respiratory status depends on more than just a respiratory rate. RR tells us nothing about the depth of breathing, if there is pulmonary shunt, and if there is adequate gas exchange. We need to take the entire respiratory picture into account. RR, SPO2, and ETCO2. As far as airway reflexes go, the Richmond Agitation - Sedation Scale (RASS) is probably a much better guide than a GCS for determining if the patient is adequately awake. Here is how the score works:
A patient with a RASS of -1 will wake up to your voice and maintain eyes contact or eye opening for >10 seconds. In an ideal world, you would probably want your overdose patient right between -1 and -2, where they open there eyes just just about that 10 seconds, and then close them again and relax. Not really sleeping, but resting comfortably. This, combined with an adequate RR, SPO2, and ETCO2, should be our goal. Why can this sometimes be hard to attain?
Think of levels of sedation like playing a game of golf. You're on the green, but you're putting from the edge of the green. That can be a hard shot! Obviously the farther away you are from the hole, the harder it is to make a shot. This is the same with reversing sedation caused by an opioid. The more negative our RASS, the harder it is to get the ball exactly where we want it (RASS of -1). Also, it is extremely easy to overshoot and wake the patient up too much. How can we fix this and make it easier and more practical?
Unlike the game of golf, doses of naloxone do not count against your score. If you were on the edge of the green, imagine how easy it would be to get the ball in the hole if you could take as many tiny shots as you needed. Easy! Tap the ball lightly until you get right up next to the hole, and then sink it! This may work for those who are responsive to painful, or who are on the edge of being alert to painful or loud / repeated loud verbal stimulation. What about those who are unresponsive? This is a gray area as we will look at in a minute. Some services or providers will not give this patient naloxone, some will. What are the pros and cons of both?
Giving the naloxone. When we were putting from the edge of the green, we knew exactly how far we had to put the ball to get the ball in the hole. It wasn't really very far, since the patient has some response. With the unresponsive patient, however, we have no idea how far from our goal level of sedation we are - and in the mean time we have a very unstable airway. It could take 0.1, or 10 mg of naloxone to reverse this patient. If we are only giving small doses (so as not to overshoot), this could take a long time. Reversing this patient also openings up the possibility of negative side effects as highlighted in my last blog.
Not giving the naloxone. Not giving the naloxone also offers a share of complications. This essentially means we either need to place something like an iGel, or we need to intubate the patient. While this is my personal preference (and the protocol that myself and many others work under), this may not be right for every service. In addition, intubation and ventilator management obviously carry serious risks (the same could be said about misuse of naloxone).
I will now post a proposed naloxone strategy that I hope will spark some good debate. This strategy focuses on managing the airway and stabilizing the SPO2 before any other intervention is performed. Like I mentioned in the outset, we need to prepare for the fight of our lives with this patients respiratory needs. We cannot underestimate our enemy, believing naloxone will be our redeemer for our many airway sins! 😈
