The Chance of Survival from Heroin Overdose When Initially Found in Cardiopulmonary Arrest

Summary:

Most patients who overdose on heroin are found to have a pulse, but are hypoxic secondary to hypopnea (with shallow and slow respirations).

Patients who overdose on heroin and are found after an un-witnessed cardiac arrest rarely survive despite cardiopulmonary resuscitation.

Based on one retrospective study, if emergency medical services (EMS) personnel are present at the time of cardiac arrest, the patient has a higher, although still small, chance of survival (Note: In this same study, only 3 of 19 (16%) patients who experienced cardiac arrest were discharged alive).

Level of Evidence: 4
Grade of Recommendation: C

Editor(s):
    Anthony J. Busti, MD, PharmD, FNLA, FAHA;
    Jeremiah Hinson, MD, PhD
    Linda Regan, MD, FACEP, FAAEM
Last Reviewed: August 2015

Landmark or Original Studies

Boyd JJ et al. Outcome after heroin overdose and cardiopulmonary resuscitation. Acta Anaesthesiol Scand 2006;50(9):1120-4. PubMed

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Sporer KA et al. Out-of-hospital treatment of opioid overdoses in an urban setting. Acad Emerg Med 1996;3(7):660-7. PubMed

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Level of Evidence	4
Study Design	Retrospective, Cohort Study
Sample Size	N = 726
Population	Adults with presumed opioid overdose
Inclusion Criteria	Those with 3 of 5 objective criteria of an opioid overdose [respiratory rate < 6/min, pinpoint pupils, evidence of i.v. drug use. Glasgow Coma Scale (GCS) score < 12, or cyanosis] were included.
Exclusion Criteria	Those with < 3 of 5 objective criteria, as above
Interventions	Prehospital administration of naloxone
Primary Endpoint	Report out-of-hospital therapy and outcomes of cohort of patients
Results	General Results: Most patients (609/726, 85.4%) had an initial pulse and blood pressure (BP). Most (94%) of this group responded to naloxone and all were transported. Of the remainder, 101 (14%) had obvious signs of death and 16 (2.2%) were in cardiopulmonary arrest without obvious signs of death. Of the patients in full arrest, 2 had return of spontaneous circulation but neither survived. Of the 609 patients who had initial BPs, 487 (80%) received naloxone i.m. (plus bag-valve-mask ventilation) and 122 (20%) received the drug i.v. Responses to naloxone were similar; 94% i.m. vs 90% i.v. Of 443 patients transported to the country hospital, 12 (2.7%) were admitted. Sub-Group Analysis: The admitted patients had noncardiogenic pulmonary edema (n = 4), pneumonia (n = 2), other infections (n = 2), persistent respiratory depression (n = 2), and persistent alteration in mental status (n = 2). The patients with pulmonary edema were clinically obvious upon ED arrival. Hypotension was never noted and bradycardia was seen in only 2% of our presumed-opioid-overdose population.
Conclusions	The majority of the opioid-overdose patients who had initial BPs responded readily to naloxone, with few patients requiring admission. Noncardiogenic pulmonary edema was uncommon and when present, hypoxia was evident upon arrival to the ED. Naloxone administered IM in conjunction with bag-valve-mask ventilation was effective in this patient population. The opioid-overdose patients in cardiopulmonary arrest did not survive.
Location	San Francisco General Hospital
Funding	Department of Emergency Services, University of California, Los Angeles, School of Medicine, USA
Comments	This cohort contains a small subgroup of patients who presented in cardiac arrest, the majority of whom showed advanced signs of death. There were no reports of survival in the remainder of this subgroup.

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EBM Focused Topic: Incidence of Naloxone (Narcan) Associated Pulmonary Edema EBM Focused Topic: Time of Onset of Naloxone Associated Pulmonary Edema EBM Focused Topic: The Mechanism for Naloxone Associated Pulmonary Edema Drug Monograph: Naloxone (Narcan) Reference Tool: Sedative Hypnotics Used in RSI or Procedural Sedation

MESH Terms or Keywords
Naloxone, Narcan, Naloxone Associated Pulmonary Edema, Narcan Associated Pulmonary Edema, Opioid Overdose

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The Chance of Survival from Heroin Overdose When Initially Found in Cardiopulmonary Arrest

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