Download Naloxone (Narcan) Induced Pulmonary Edema

Naloxone (Narcan) Induced
Pulmonary Edema
John Cunha, DO, FACOEP
Holy Cross Hospital
Oakland Park EMS Medical Director
Naloxone (Narcan) Use
 Used
to reverse the respiratory
depression effects of opioids
 Dosed from 0.4mg-4mg per dose
depending on the patient’s response
 Given in small doses until patient’s
respiratory rate increases
Naloxone (Narcan) Major
Side-effects
Hypertension
Ventricular
arrhythmias
Cardiac arrest
Seizures
Pulmonary edema
Flash Pulmonary Edema
 Extremely
rare event
 First reported in anesthetized lab animals
 Seems to be related to higher doses of
Narcan given and rapidity of reversal
 IV infusion may be more likely to
precipitate rapid reversal and side-effects
Flash Pulmonary Edema-SIGNS
Sudden
dropping O2 sat
Tachypnea
Hypertension (could be followed by
hypotension)
Feeling of Shortness of Breath
Rales throughout lung fields
Flash Pulmonary Edema-WHY?
 In
opiate dependent patients, naloxone causes
catecholamine (epinephrine) release leading to
pulmonary edema
 The mechanisms for the increase in epinephrine
following the administration of naloxone include its
direct antagonizing effects on mu-opioid receptors
 Sudden
overwhelming drug withdrawal
symptoms-causing “Fight or Flight”
Flash Pulmonary Edema-WHY?
 Increases
in plasma concentrations of
epinephrine by 30-fold—“Fight or Flight”
 HUGE Increases in Cardiac Output
 Increases in blood pressure and heart rate
 The above hemodynamic effects appeared to
be more pronounced if the baseline PCO2
was elevated (Patients with longer downtime)
Flash Pulmonary Edema-WHY?
 In
the lung tissue epinephrine leads to leaking
of pulmonary capillaries
 This leads to accumulation of pulmonary fluid
(Rales on auscultation)
 May also be related to the release of
histamine within the lung tissue
 Secondary to the epi or the opioid itself
This
is the edema
Flash Pulmonary Edema-SIGNS
Sudden
dropping O2 sat
Tachypnea
Hypertension (could be followed by
hypotension)
Feeling of Shortness of Breath
Rales throughout lung fields
What to do???
 Ensure
adequate oxygenation and ventilation
 Give narcan in small frequent doses until
respiratory depression is reversed
 High flow oxygen
 Nitroglycerin 0.4mg SL if no hypotension (repeat
per protocol)
 Lasix 20 mg IV if no hypotension (If available)
 Administer CPAP with 10 cm H2O PEEP (medical
procedure 4.12)
 Intubate if necessary
SOURCES
 http://www.ebmconsult.com/articles/mechanism-
naloxone-related-pulmonary-edema-opiateopioid-overdose-reversal
 Florida Regional Common EMS Protocols
 Chest, Oct. 2007, Vol. 132, No. 4

http://journal.publications.chestnet.org/article.aspx
?articleid=1094181