I... Can't... Breathe. I... Can't... Breathe.

"Hey guys, how's it going?" An officer asked as my partner and I walked past.

"Good man, how are you?"

"Eh, livin' the dream. They're down there," he pointed down the small embankment.

"They Narcan'd him already."

"Okay, thank you!" I said will a smile while simultaneously trying not to die on the way down the muddy slope.

We walked over to the group of firefighters and other officers standing over the patient who looked very anxious/uncomfortable, jittering.

"Bystanders gave him Narcan. 16 mg of it." Woof.

The patient was a 20-year-old guy with a history of opioid abuse, but no other diagnosed medical problems. He seemed very short of breath.

I examined him and found him to be tachycardic, tachypneic, and short of breath.

"I... Can't... Breathe. I... Can't... Breathe."

I listened to his lungs - They seemed diminished, but relatively clear.

16 mg is a lot of naloxone... Like, way too much, especially in the early stages of treatment and especially when the patient isn't breathing on their own. There is an inherent danger in that.

The goal of standard opioid OD management is to provide adequate ventilation BEFORE administering naloxone. There are a multitude of reasons behind this...

What I like to do is get on scene, start ventilating with the BVM, and establish a baseline. I get vitals, including a glucose, and THEN I will give naloxone, usually around the 3-5 minute mark, AFTER ventilation has been established.

Personally, I like to give naloxone IM (or IV). I'm actually going to let you all in on a little secret: I have only given naloxone via atomizer/intranasally once - In my entire career. I like the IM route the best. It gives a nice, stable administration and I've always had great experiences with it. I have absolutely no data or studies to support this statement, but anecdotally, I think it makes more sense to give it this way. I like the slower wake-up and the good, stable, generally predictable absorption you get from an IM injection. Turns out, when someone snorts fentanyl and cocaine 6 times a day, their nares get pretty fried and not very reliable... Hence why people go from snorting to injecting over time - Who knew? Anyway, I give every patient 2 mg IM, followed by another 2 mg as needed.

The whole slow, start an IV, give 0.4 mg, wait, give 0.4 mg, wait, thing is NOT how you treat an apneic patient. Give them 2 mg. IM, IN - whichever.

Usually, if my initial 2 mg hasn't worked I will repeat the dose once and then, if necessary, escalate to an IV where I will give 0.5 mg doses at a time, up to 2 mg. Keep in mind that this takes time. Expect 3-5 minutes before an IM or IN dose of naloxone works. Don't wait 60 seconds and then give 2 more mg. Give it a few minutes to work. If I see positive progress, I'll keep going to my personal goal of a RASS of -2 or so. If not, I might try 2 more mg - but depending on the patient's condition, the 6-8 mg mark is usually where I start to consider intubation.

Lots of people advocate titrating naloxone to a respiratory drive - and that's a perfectly reasonable approach. I like it a little better than that... I titrate to mental status. I want the patient to briefly wake up when I talk to them and then immediately go back to sleep if I leave them alone. The Richmond Agitation and Sedation Scale was developed to measure and titrate sedation in the ICU setting. It goes from -5 (unarousable) to +4 (combative). A -2 is briefly arosable to voice - Perfect. Let's be real, this is the level these folks paid for anyway... They are well above "breathing" and managing their airways. They can wake up, look around, etc., and then go right back to sleepy-time. They're happy, I'm happy, the hospital is happy.

That is, assuming I am going to transport. Usually, in the system I am used to, we don't transport most of the time. We wake them up nice and slow and offer treatment/transport, but they can refuse assuming certain criteria are met, and we can give them leave-behind naloxone and even, as a very recent intervention, give them suboxone.

But this didn't matter that day, right? Because this dude got 16 mg of Narcan, all at once, without any oxygenation or ventilation first.

We carried him up the embankment, got him on the stretcher, and loaded him in the ambulance. He was tachy in the 120s and VERY short of breath. His SpO2 was 70%. UtOH.

"I. Can't. Breathe. Help." He was working.

I listened to this lungs: Rales. Rales all the way up. He then spit up pink, frothy sputum. This was the first time I had ever actually seen it.

Opioid-associated pulmonary edema and ARDS are pretty well documented in the literature. It's a known, but very rare complication of opioid overdose and/or naloxone administration.

No one really knows why this happens, but there are a bunch of theories. Here is what I THINK may have happened to this guy, based on a couple of the more popular theories:

I think he overdosed on opioids - that part is obvious - and he became apneic. I think a good samaritan then saw him overdosing and tried to help by giving him WAY too much naloxone, WAY too quickly, and without ventilating him or maintaining his airway with a BLS maneuver. This caused an issue where the patient had a return of his respiratory drive without the return of his mental status. He remained obtunded without a patent airway and took a deep breath. This can lead to deep inspiration against a closed glottis, causing a negative pressure injury to the lungs. Alternatively, waking up that quickly with that much naloxone on board can cause a MASSIVE catecholamine dump, which can also contribute to rapid pressure changes that mess up the Starling forces of the capillaries/tissues.

Shameless plug: I did a whole video on Starling forces last year - It should be in the membership videos on the website! So check that out if you want more.

Anyway, it could even be a healthy combination of the two... Who knows? The point is, this guy is very sick and needs some rapid interventions.

First, it was time for CPAP... Because his sats were in the 70s on the NRB mask and that was uncomfortable to look at.

When I put someone on CPAP I always try to do it in an escalating fashion. First, I place the mask on their face and then I let them hold it there themselves. This does two things for me, 1) It's sorta a mental status test - can they tolerate the simple command and do they have the mental capacity to maintain the seal? 2) It lets them be in control of the mask/procedure. I've noticed patients find this comforting. They can't breathe, right? And now I'm shoving a mask on their face... not helpful. At least not the appearance of helpful, anyway. When I do this, I use just the mask. The masks I'm used to have a big hole in the front where the circuit connects - They can easily breathe through just the mask.

No pressure yet. Next, I plug the circuit in and turn it on to 5 of PEEP. I NEVER put that circuit on the patient without it being on - that starves them of air. With it on, I plug the circuit into the mask and still just let them hold it, coaching them the entire time. THEN I will place the straps.

I've always had really good luck with this technique - until this call, anyway. Because placing this patient on CPAP went about as well as you'd expect... He didn't like it. He pulled that mask off and fought it the whole time. His sats stayed in the 70-80s all the while - not optimal.

Finally, it was time to go sleepy-time.

My partner, like the rockstar he was, got a solid line and we set up for the intubation. We planned, we prepped, and we pushed the meds.

First, we used a lower dose of ketamine to make him chill out for a bit. This is a "delayed" style of intubation where you give some sedative to optimize the patient safety. With the patient sleepy, we were able to pre-ox a bit using a combination of jaw thrust, CPAP, and a nasal cannula. Sweet. Sats got up into the mid-high 80s and we recognized that that was probably the best we were going to get. Then came the rest of the ketamine and the rocuronium.

The tube went fine - it was an easy view and passage.

We then switched to bagging with a pedi BVM. Recognizing the ARDS-like picture we knew we couldn't risk big volumes. We used a PEEP valve and cranked it right up to 10 and then 15... His sats stayed in the 80s.

We reached the hospital pretty quickly and gave our handoff - within 30 minutes he was crashed onto ECMO. He was very sick.

I think we take overdoses for granted sometimes. Especially in urban areas, they have become routine. At least for me, when I'm sent to an OD I have a certain bias in my head - I know how the call is going to go. I am going to use a BVM, give a little Narcan, get a refusal, and call back in service. No big deal - I will do 4 more of the exact same call this shift. I don't picture the catastrophic anoxic brain injury that seizes on us or the ARDS/pulmonary edema patient who tried to die the whole way to the hospital... I don't picture the polypharm patient who we wake up nice and gently and then snaps suddenly because he now has an unopposed cocaine rage. I picture the routine. This call, at least for me, was a good wake-up call and a reminder that even somewhat easy calls can become challenging really quickly.

What are your thoughts? Has this kinda thing ever happened to you on a call? How do you give Narcan? Let me know below!

-Dean Stockley