1:30 sec video Naloxone Hydrochloride
https://www.youtube.com/watch?v=35lBf5s-iro as per all medicine, see below for CPR guidelines etc.
Layperson training the following would be charged with ‘Conspiracy to council mass murder’
Over a million respiratory emergency patients presented to hospitals per year in Ontario. 7,000 out of hospital cardiac arrests/year in Ontario, a lot less are sudden witnessed cardiac arrests the only time chest compression’s only may be of benefit, blood is still oxygenated. Train tens of thousands of laypersons all the signs of respiratory emergency. Then tell them to give chest compressions only, lay responders are eager to follow the nurses instructions thinking they are saving lives. Majority of morbidity and mortality is happening to those who never used a drug in their lives.
Ontario Naloxone Training Video
Signs are respiratory emergencies, not cardiac arrest
Naloxone saves lives
You would think it brutal to withhold the air from someone. Every second you withhold the air from respiratory emergency patients every cell, tissue and organ is dying lack of oxygen.
Training Power Point Slide 23
Training Webinar Removed mid August 2015
http://www.instantpresenter.com/ohtn/E956D7808049 See Webinar info here http://www.slideshare.net/GaryThompson11/webinar-complete-51744907
Waterloo Region Crime Prevention Council
“My childhood friend was completely blue….started with chest compressions, did’nt seem to do have a great affect” Yes Joe you are quickening Wade’s death, Joe took the training 3 days prior. You just heard a crime.
Soon to happen all across Ontario? June 1st 2015 Report Original report ‘Prescription for Life’ My response https://www.linkedin.com/pulse/prescription-life-june-1-2015-gary-thompson
Naloxone left elsewhere http://www.harmreductionjournal.com/content/6/1/26
Quote “most participants did not carry the naloxone with them consistently and consequently it was generally not available if they witnessed an overdose.” Other studies report same 20% ++ of the time left elsewhere. Chest compressions only used in Ontario?
Dr. Ewy THE WORLD EXPERT on chest compressions only. He is pissed 20 years of research being thrown down the drain by Public Health Ontario. He phoned me “Gary don’t stop what you are doing” His quote “It’s OK to be cantankerous and opinionated if you’re right,” he says. “And we’re right.” “The advisory applies only to cases of adults in cardiac arrest, not children, and excludes drowning and drug-overdose [any poisoning; asphyxia] cases.” “Some doctors worry that bystanders can get confused and do only chest compressions in drug-overdose [any poisoning or asphyxia] and drowning cases.” Public Health Ontario is confusing and killing everyone.
Thousands of resuscitation experts write the following CPR guidelines every five years
I was just published (moderated comments) in the 2015 AHA and ILCOR CPR guidelines about this life threatening intervention.
2015 ILCOR Part 3 ‘Adult Basic Life Support and Automated External Defibrillation’ See page 5 ‘Opioid Overdose Response Education’ My moderated comments hyperlinks ALS441 and BLS 891 Read my response to Dr. Dailey
Quote Treatment Recommendation
“No treatment recommendation can be made for adding naloxone to existing BLS (Basic Life Support) practices for the BLS management of adults and children with suspected opioid-associated cardiac or respiratory arrest in the prehospital setting.”
Response: ‘existing BLS practices’ Means refer to 2010 CPR guidelines which state, rescue breathing then Naloxone continue rescue breathing until patient breaths adequately on their own.
Hyperlinks not working?? see here http://www.slideshare.net/thompsongary/2015-aha-ilcor-cpr-guidelines-bls-891
2015 AHA Part 10 ‘Special Circumstances of Resuscitation’
Quote page 501 third paragraph “The following topics were last updated in 2010: Part 12.7 Toxic effects”
SECTION ON POISONING (DRUG OD) LEFT OUT EVEN THOUGH POISONING (drug OD) is 10 times more prevalent than out of hospital cardiac arrests. See page 504 my moderated comments BLS 891 & ALS 441
Quote: “opioid toxicity is associated with central nervous system (CNS) and respiratory depression that can progress to respiratory and cardiac arrest” “It is reasonable to base this training on first aid and non–healthcare provider BLS recommendations”
“should support ventilation and administer naloxone to patients” “Bag-mask ventilation [rescue breathing same] should be maintained until spontaneous breathing returns”
2015 ILCOR & AHA 70+ references on opioid overdose No mention chest compression’s only. https://aliascpr.wordpress.com/2015/12/13/2015-ilcor-and-aha-references-opioid-od/
Poisoning (drug OD) still in the ERC guidelines 2015 2015 European Resuscitation Council Guidelines for Resuscitation
Section 4. Cardiac arrest in special circumstances TOXINS p.165
Quote “fewer adverse events when airway opening, oxygen administration and ventilation are carried out before giving naloxone” “There are no studies supporting the use of naloxone once cardiac arrest associated with opioid toxicity has occurred.” [Brain dead lack of oxygen.]
2010 ILCOR Part 8.5 Drug Overdose and Poisoning http://www.resuscitationjournal.com/article/S0300-9572(10)00453-3/fulltext#sec2260
“use assisted ventilation before giving naloxone in opioid-poisoned patients”
“ventilation should be assisted using a bag-mask, followed by naloxone, and tracheal intubation if there is no response to naloxone”
[bag-mask or tracheal intubation same as rescue breathing for layperson]
2010 American Heart Association Guidelines Part 12.7: Toxic Ingestions
“Practically every sign and symptom observed in poisoning can be produced by natural disease, and many clinical presentations associated with natural disease can be mimicked by some poison” Doctors can misdiagnosis the cause of respiratory emergency, but know straight away it’s respiratory not cardiac arrest, the signs are completely different. A child can tell the difference.
“ventilation should be assisted by a bag mask, followed by administration of naloxone and placment of an advanced airway if there is no response to naloxone” [Bag mask or advanced air same as rescue breathing for layperson]
2010 European Resuscitation Council Guidelines See Part 8.b Poisoning http://resuscitation-guidelines.articleinmotion.com/article/S0300-9572(10)00441-7/aim/
“fewer adverse events when airway opening, oxygen administration and ventilation are carried out before giving naloxone” “There are no studies supporting the use of naloxone once cardiac arrest associated with opioid toxicity has occurred.” [Brain dead lack of oxygen.]
World Health Organization 2013 Page 7 http://www.unodc.org/docs/treatment/overdose.pdf
“In the case of suspected opioid overdose, any respiratory arrest should be managed with assisted breathing and/or oxygen while waiting for naloxone to be administered and take effect.” “If naloxone is not available, overdose can be treated with respiratory support, either
mouth-to-mouth, with a bag and mask, or with pressure-controlled ventilation.”
Naloxone Hydrochloride Monograph 2015
“Administration should be accompanied by other resuscitive measures such as administration of oxygen, mechanical ventilation, or artificial respiration.”
International Programme on Chemical Safety ” Since many of these patients suffer from impaired respiration or respiratory arrest, it is extremely important to give oxygen and to support ventilation immediately while waiting for naloxone to beavailable for injection. If ventilation is under control and cyanosis is regressing” “adequate ventilatory support must be given.”
Harm Reduction Coalition Page 60
“When someone has extremely shallow and intermittent breathing (around one breath every 5-10 seconds) or has stopped breathing and is unresponsive, rescue breathing should be done as soon as possible; it is the quickest way of getting oxygen to someone who has stopped breathing. If you are performing rescue breathing, you are getting much needed air into someone’s body who will die without it; the difference between survival and death in an opioid overdose depends on how quickly enough oxygen gets into the person’s body.”
2011 Poisoning and Toxicology Handbook pages 35:(83) & 85:(132) https://ilmufarmasis.files.wordpress.com/2011/07/toxicology-and-poisoning-handbook.pdf
“In this manner, the initial approach to the poisoned patient should be essentially similar in every case, irrespective of the toxin ingested, just as the initial approach to the trauma patient is the same irrespective of the mechanism of injury. This approach, which can be termed as routine poison management, essentially includes the following aspects: Stabilization: ABCs (airway, breathing, circulation); administration of glucose, thiamine, oxygen, and naloxone” [More accurate ABCD (airway, breathing, circulation, drugs); if no heart beat, no use giving Naloxone. Chest compressions only is just making sure you stay dead. Cardiac arrest patient needs ACLS methods: vasopressors, open chest cardiac massage, electro-shock paddles etc. brain dead lack of oxygen]
“Initial measures include airway protection, vital sign monitoring, and administration of naloxone, an opiate antagonist.”
Poisonings in Ontario, any poisoning is a respiratory emergency
http://www.parachutecanada.org/downloads/policy/WhitePaper_Poisoning.pdf page 9
“Ontario Poison Control Centre over 60,000 calls 2008 …. 42% of poison exposures involved children”
Compressions only CPR AHA Guidelines 2010 Part 4
“Cardiopulmonary resuscitation (CPR) is a series of lifesaving actions that improve the chance of survival following cardiac arrest.” “Immediate recognition of cardiac arrest” [signs of cardiac arrest totally different than respiratory emergency: No pallor; huge pupils; agonal gasps; seizure]
Sudden cardiac arrest Agonal Breathing Video different signs than respiratory emergency
Dissecting the ACLS Guidelines on Cardiac Arrest from Toxic Ingestions Emergency Medicine News: 2011;33(10)p.16-8 2011 – Volume 33(10)p. 16-8 “cardiac arrest and severe drug toxicity in the pre- and post-arrest phase are different scenarios. Don’t confuse post- or pre–arrest toxicologic interventions with the actual cardiac arrest event.” “there is no drug, antidote, or intervention that alters the outcome of cardiac arrest from a toxin”
CARDIAC ARREST IS SECONDARY TO RESPIRATORY ARREST A COMPLETLY DIFFERENT ANIMAL THAN A SIMPLE CARDIAC ARREST 2010 American Heart Association Guidelines for Cardio pulmonary Resuscitation and Emergency Cardiovascular Care Field JM, et al Circulation 2010;122(18 Suppl 3):S639 “Severe poisonings alter cellular receptors, ion channels, and chemical pathways in a manner different from cardiac arrest secondary to coronary disease or other more common entities. Although managing cardiac arrest after toxic exposures similarly begins with airway, breathing, and circulation, cardiac arrest due to a medication overdose or toxin conjures up interventions of a special nature. Although a few antidotes have the potential to rapidly neutralize or reverse the toxic effects of drugs in the still living, the majority of one’s arsenal to treat cardiorespiratory collapse secondary to a drug overdose is primarily basic support.” [rescue breathing]
Canadian Red Cross CC only
“Compression-only CPR should not be used when the oxygen in the victim’s body has likely been used up, such as with a drowning victim or when a [any] respiratory emergency may have caused the cardiac arrest.” “When an infant or child’s heart stops, it’s usually because of a respiratory emergency, such as choking or asthma, which uses up their body’s oxygen.”
Baby suffering a seizure, respiratory emergency PR only (rescue breathing), not CR only, nor CPR http://youtu.be/mSe2LUysxcg
Suspected Opioid Overdose Management Protocol using Naloxone. Manitoba 2008 http://www.gov.mb.ca/health/ems/protocols/docs/opioid_overdose_naloxone.10.08.pdf Step 4.”Initiate basic life support treatment measures, including supplemental oxygen [rescue breathing].- these take precedence over management using this protocol” Step 8. “If the patient is not hypoglycemic and the patient has a respiratory rate less than 12 per
minute, administer naloxone.”
Decision Support Tool (DST) for the use of naloxone HCl (Narcan) in the management of suspected opioid overdose in outreach and harm reduction settings. British Columbia, May 2013 http://www.bccdc.ca/NR/rdonlyres/43016F4A-FA31-4717-90E0-553A09A5945C/0/NaloxoneDSTBCCDCMay302013.pdf Step 1. “Apply O2 mask [rescue breathing] according to agency policy/availability. Step 2. Administer naloxone 0.4 mg to 0.8mg IM or SC. Step 3. Repeat dose of 0.4mg every 3-5 min up to a maximum of 2-5 mg and until RR > 10-12/min [continue rescue breathing] Step 4. Monitor respiratory rate every 5 min for 15 min then every 10 min [rescue breathing]”
Guidelines for Administration of Naloxone (Narcan) for Opioid induced Respiratory Depression. NHS Foundation Trust http://www.dbh.nhs.uk/Library/Pharmacy_Medicines_Management/Formulary/Formulary_S4/Guidelines%20for%20Administration%20of%20Naloxone-1.pdf Step 3. “Administer 100% oxygen via a non re-breathing mask. Step 4. Seek urgent assistance from on-call anaesthetist/outreach team/pain team. Step 5. If respiratory arrest has occurred ring 2222. Step 5. Support ventilation by face mask or Ambu-bag if rate declines further or if respiratory depression persists. Step 6. Administer 100-200 micrograms naloxone IV immediately.”
NALOXONE ACCESS:A Practical Guideline for Pharmacists. College of Psychiatric and Neurologic Pharmacists 2015 Nebraska https://cpnp.org/_docs/guideline/naloxone/naloxone-access.pdf “Rescue breathing involves essentially breathing for someone else. By providing rescue breathing during an opioid overdose, the rescuer can potentially prevent the patient from developing organ damage.”
Naloxone: Vermont Statewide EMS protocol 2013
Slide 47 Critical Reminder “Be sure to ventilate properly as needed”
Winnipeg Regional Health Authority July 2010 http://www.virtualhospice.ca/Assets/Narcan%20protocol_20120110163651.pdf “Administer oxygen [rescue breathing] 5 liters/min. nasal prongs (if available). Administer naloxone…. until patient rouses and respiratory rate greater than 10 breathes/min”
Intranasal naloxone protocol for opiate overdoses. http://intranasal.net/Treatmentprotocols/Naloxoneprotocol/Naloxoneprotocol.htm “1.Assess ABC’s – Airway, Breathing, Circulation 2.For pulseless patients, proceed to ACLS guidelines [beyond the scope of laypersons; trauma team – probably brain dead lack of oxygen]. 3.Apnea with pulse – Establish oral airway and begin bag ventilation with 100% oxygen 4.Load syringe with 2 mg (2 ml) of naloxone and attach nasal atomizer 5.Place atomizer within the nostril 6.Briskly compress syringe to administer 1 ml of atomized spray. 7.Remove and repeat in other nostril, so all 2 ml (2 mg) of medication are administered 8.Continue ventilating patient as needed”
Jason M. White and Rodney J. Irvine ‘Mechanisms of Fatal Opioid Overdose’ Addiction 1999; (7) 961-72 Quote p. 961 “The dangers of opioid overdose have been recognised for as long as the use of opium itself” p. 962 “the primary mechanism responsible is opioid-induced depression of respiration with resulting hypoxia and death.”
Compendium of Pharmaceuticals and Specialties 2015 page 2143
“Establish adequate respiratory exchange through the provision of a patient airway and institution of assisted or controlled ventilation.” “Naloxone should not be administered in the absence of clinically significant respiratory or cardiovascular depression. Oxygen, iv fluids, vasopressors and other supportive measures should be used as indicated.”
[ACLS methods, all cells tissues and organs have suffered sever damage hypoxia, prognosis poor]
Physicians Desk Reference 2015 page 2105
“In case of overdose, priorities are the re-establishment of a patent and protected airway and institution of assisted or controlled ventilation if needed….Cardiac arrest or arrhythmias will require advanced life support [ALS] techniques.” ALS is beyond the scope of laypersons “Naloxone may not be effective in reversing any respiratory depression produced by buprenorphine.”
Goldfrank’s ‘Toxicologic Emergencies’ [electronic resource] 2015 Chapter 38 page 15
“The consequential effects of acute opioid poisoning are CNS and respiratory depression. Although early support of ventilation and oxygenation is generally sufficient to prevent death, prolonged use of bag-valve-mask ventilation and endotracheal intubation may be avoided by cautious administration of an opioid antagonist.” “Differentiating acute opioid poisoning from other etiologies with similar clinical presentations may be challenging.” [doctors have trouble diagnosising one respiratory emergency from another]
Haddad & Winchester ‘Clinical Management of Poisoning & Drug Overdose’ 3rd Ed. Chapter 36 p512
“The initial evaluation and management of opioid overdose focuses on stabilization. Priorities include assessment and establishment of effective ventilation and oxygenation. Ventilatory support can usually be safely provided with a BVM device while awaiting the reversal of respiratory depression by an opioid antagonist.”
Martindale ‘The Complete Drug Reference’ 35th Ed pages 87-8 & 1309 “Death may occur from respiratory failure…The triad of coma, pinpoint pupils, and respiratory depression is considered indicative of opioid overdoseage.” “Intensive supportive therapy may be required to correct respiratory failure” “It is used to reverse opioid central depression, including respiratory depression…”
Lange “Poisoning and Drug Overdose” 6th Ed 2012 Opioids pages 1 & 311-12
“many steps may be performed simultaneously (e.g. airway management, naloxone..)”
“The most common factor contributing to death from drug overdose or poisoning is a loss of airway-protective reflexes with subsequent airway obstruction caused by the flaccid tongue, pulmonary aspiration of gastric contents, or respiratory arrest. All poisoned patients should be suspected of having a potentially compromised airway.” “…causing sedation and respiratory depression. Death results from respiratory failure, usually as a result of apnea or pumonary aspiration of gastric contents.” “Maintain an open airway and assist ventilation if necessary. Administer supplemental oxygen.”
Annotated medical info my comments #13-14
TIM NOONAN TOP EMS
Dr.Gabor Mate’s quote June 8, 2013 Toronto ‘All Saints Church’ http://www.medicaldaily.com/pulse/addiction-specialist-dr-gabor-mate-explains-why-punishing-addict-ineffective-330456
Some punishing of the OD patient and anyone else that suffers any respiratory emergency. G.M. Quote “Vancouver 2004 the RCMP tried to stop an overdose resuscitation program. Dr. Mate taught the RCMP some wisdom, these disenfranchised will not only save each other but anyone else that suffers any respiratory emergency. Program was allowed to continue.” In Toronto and other parts of the province Public Health is teaching not only how to maim and kill the poisoned (drug OD) but anyone else that suffers any respiratory emergency.
Moderated comment Canadian Association Of Emergency Physicians Airway Intervention and Management in Emergencies Public Health Ontario needs some training on basic airway management [rescue breathing]. Training tens of thousands of laypersons all the signs of respiratory emergency, then teaching them chest compressions only.
Live human study Development and implementation of an opioid overdose prevention and response program in Toronto, Ontario. http://journal.cpha.ca/index.php/cjph/article/view/3788 Emergency physicians and families are dealing with the needless complications and needless suffering from this live human study.
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. https://www.linkedin.com/pulse/agnotology-gary-thompson
Correspondence from Public Health
A favoured response from professors etc. “…our experts…” when they can’t substantiate a claim.
Don’t Forget to Breathe @GaryCPR