In comes a 34-year-old male who is obtunded with pinpoint pupils and breathing at five times a minute; likely due to heroin abuse. He wakes up after Narcan is appropriately administered, but now he wants to leave. What is the risk of death if he leaves? Do we restrain him against his will to monitor him for possible recurrent respiratory depression?
We have some pre-hospital literature that looked into this issue. The studies looked at patients who refused care after pre-hospital providers administered Narcan for a suspected opiate overdose. They then searched the death registry to see if those patients later died after refusing care (transport to the hospital).
Wampler et al. looked at 552 patients and found that no one died until at least 4 days later (1). These deaths four days later were unlikely to be from the initial overdose. A second study recently published in March of 2016 had 205 patients and showed only one death in 24 hours (2). Two others died in the 30-day follow up period which again were not likely due to the initial overdose. Combining the numbers from these two studies equates to 1/757 (0.13%) deaths.
There are limitations with all studies, but death seems unlikely after refusal of care post-narcan administration. However, our practice should not change as it relates to monitoring patients for about 4 hours to those willing. Recurrent respiratory depression is a real concern particularly seen in those patients who abuse long acting opiates. Despite this, some patients who have the capacity to make decisions may not choose the wisest care plan and may leave AMA. We must still make considerable attempts at providing substance abuse referrals and other appropriate resources as these patients are in great need of help.
Post by: Joe Bove (@jjbove08)
- Wampler D, Molina D, McManus J, Laws P, Manifold C. No deaths associated with patient refusal of transport after naloxone-reversed opioid overdose. Prehosp Emerg Care. 2011;15(3):320-324.
- Levine M, Sanko S, Eckstein M. Assessing the Risk of Prehospital Administration of Naloxone with Subsequent Refusal of Care. Prehosp Emerg Care. March 2016:1-4.
As a residency we have been wanting to get more involved with our surrounding community instead of just interacting with the residents of Paterson in the ED. A couple weeks ago we went to Habitat for Humanity in Paterson to help with some construction instead of being cooped up at St. Joe’s for conference. Joe “Handy-man-chester” single-handedly constructed a single-family home in 8 hours while Dr. Patel did an amazing job observing everyone else working and providing endless amounts of encouragement. It was a lot of fun and we’ll be back soon!
We’ve had a bunch of publications in both peer-reviewed and non peer-reviewed sources over the past few weeks! Check them out when you get a chance:
Traficante and Kashani in the Journal of Clinical Toxicology talking about a Massive Calcium Channel Blocker OD
McGovern and D’Amore in Annals of Emergency Medicine talking about Peds EM Education
D’Amore, McGovern and McNamee in ACEP Now talking about End-tidal for DKA and COPD
Pena, Mota and McGovern in AAEM/RSA Blog going over the elusive Porphyria diagnosis and management
DeFranco and McGovern in ACOEP’s Fast Track talking about Isolated Bandemia
Let’s face it, we’ve all done it. And, believe me when I tell you all the cool cats are doing it, too. Of course, I am referring to the use of whole blood to determine a woman’s pregnancy status in the Emergency Department using the urine pregnancy test strip.
Did you know that the common ICON 25 Beckman-Coulter hCG tests are actually approved for both urine and serum? Don’t feel bad; I didn’t until I read a recent article. Whole blood, which is comprised of serum (54%), hematocrit (45%) and leukocytes/platelets (1%), was rumored to detect a woman’s pregnancy status. Now, we have research that confirms our suspicions and demonstrates that whole blood pregnancy testing performs quite excellently.
In a study published in 2012, whole blood pregnancy tests were found to be 96% sensitive, 100% specific with a negative predictive value of 98% and positive predictive value of 100%. Translation: Trust a positive test, it will not be wrong. Can it miss? Yes, it can; however, there’s a good chance that the urine test will be negative at that point, too (5 of 9 that were missed with whole blood testing of the studied 425 pregnancies were also negative on the urine testing—the other 4 of 9 did not undergo urine testing).
As troops on the front lines of medicine, we are presented often with little time to think or to act. We are adroit at putting puzzle pieces together, often with little information. This is our creed and such is our nature. It is during these critical cases, that the application of using whole blood pregnancy testing has its greatest application.
Post by: Raphael Brancato, DO (@DrRayFields )