WHY WON`T HE WAKE UP?

     Attack One responds to a residence for a "man down." In the front room of a small boarding house, they find a 40-year-old male in a bed. "I can't wake him up," the boarding house manager reports. "He's had a cold, but otherwise hasn't been having any medical problems. I gave him some cold medicine last night."

     The man is unresponsive and breathing slowly. He has a pulse rate of 72 and is perfusing well. He responds only to deep painful stimuli. No signs of trauma are present, nor are there smells of intoxicating substances.

Treatment
     Secondary evaluation reveals small, equal pupils. The patient's oximetry reading is 78%, so he's provided oxygen at 15 lpm via NRB. His mouth is clenched tightly and cannot be opened to intubate him orally. He has a severely deviated nasal septum, so the crew can't pass a nasotracheal tube, either.

     As the patient is secured for transport, the boarding house manager prepares his belongings for the crew to take. She finds his medicines in the house cabinet, and hands one crew member the bottle of "cold medicine" she'd given the patient the night before. The bottle says MS Contin. "That's some pretty powerful cold medicine," the crew member remarks.

     A look of horror appears on the manager's face. "Oh, no!" she exclaims. "That's medicine for another resident!" She confirms that the patient received two or three doses of this wrong medication, the last administered at about 0100 hours. MS Contin is a powerful liquid form of morphine sulfate, typically reserved for patients with cancer or other painful long-term illnesses.

     The Attack One crew notes the clinical triad of opiate overdose: altered level of consciousness, decreased respirations and pinpoint pupils. The reversal agent for opiate drugs is naloxone, which typically reverses all three effects. Reactions to this medication can vary widely, although it is effective at some dose against all narcotic pain medications and opiate street drugs derived from heroin. Naloxone is often used in the operating and recovery rooms to reverse the effects of narcotics used to put patients to sleep for surgery. Providers experienced in these areas have a teaching reminder regarding its use:

     The correct dose of naloxone is just enough to get the patient to breathe adequately and begin to wake up.

     The patient here is administered small doses of naloxone up to the maximum amount permitted in the protocol (4 mg). He begins to breathe a little more frequently, and his pupils increase in size, but he does not wake up. With BVM assistance, his oxygen saturations improve into the 90s.

Hospital Course
     The patient is unable to be intubated nasally or orally by the ED staff, so they perform a rapid-sequence intubation. His saturations then increase to 100%, and BVM compliance is good. He begins to open his eyes slowly to verbal stimuli, but continues to need ventilation assistance.

     No other abnormalities are found on full ED evaluation. His slow response to naloxone and failure to awaken quickly are due to his overnight episode of breathing inadequately and subsequent low oxygen levels. A slightly longer period of inadequate ventilation likely would have caused severe long-term brain injury, so the timely work of the Attack One crew prevented a bad outcome. He recovers slowly but completely, returning to his baseline function, and is discharged five days later.

Case Discussion
     This patient had accidentally been administered medication intended for another patient, and that medication severely depressed his respirations.

     Narcotic pain medications and opiates are all derivatives of the opium of poppy plants. Opiates have a millennium-long history of abuse. Narcotic pain medications have very important uses in healthcare, and are used by essentially every individual at some point in their life. The use of narcotic medications in the operating room for anesthesia was an important advance in patient care, and anesthesia personnel developed naloxone as a medication to reverse essentially all effects of opiate substances. That powerful reversal effect is useful in the recovery room, but can be dangerous in the emergency environment. Naloxone will produce immediate symptoms of withdrawal for patients with long-term use of narcotics or opiates, an effect called "going cold turkey." Administering naloxone rapidly and/or at a high dose can cause such patients to get agitated or violent, vomit profusely and become soaked in sweat, and drive their blood pressure to high levels. Some patients will have seizures. In some long-term opiate-abusing patients and patients with severe illness from cancer, going cold turkey can be fatal.

     Naloxone must be administered with extreme care. Finding patients who are likely suffering from opiate overdoses is accomplished by looking for the symptom triad described above: altered level of consciousness, decreased respirations and pinpoint pupils. Examining the patient for inappropriately small pupils is critically important, as this is a consistent effect of opiates. But the most dangerous effect for the patient is the depressed respiratory status, prolonged periods of which can cause hypoxic brain damage. This patient narrowly avoided that complication.

Customer Service Priorities
     What other people would be affected by this incident?
     The boarding home staff should be questioned regarding the dispensing of medications. This may not be a responsibility of EMS providers, particularly if they're doing critical patient care, but law enforcement or other regulatory personnel should ask, "Are they qualified or licensed to perform that function?" In this case, the staff was qualified, and law enforcement personnel on scene confirmed the mixup was an accidental event, with two bottles that were virtually identical on the shelf next to each other.

     Was the optimal treatment path followed?
     Victim management entailed providing the needed oxygen and ventilation, although the airway could not be secured. Definitive airway management by the ED staff using drug-assisted intubation is a good option for many patients. There was a slight delay in recognizing the source of the altered level of consciousness, but history from the caregivers provided the missing element. The cause of the decreased mental status could also have been a stroke, an unusual seizure, meningitis or a bleed into the brain. Naloxone administration reversed the immediate cause of altered consciousness, but this patient's brain required more time to recover from the hypoxic insult.

     What further customer service elements were critical for the management of this incident?
     The patient seen for altered level of consciousness required emergency intervention to prevent a bad outcome. But there was another patient to consider in this incident: the one who was supposed to get the wrongly administered morphine.

     The Attack One paramedic in charge addressed this by returning to the boarding home to check on the status of the MS Contin's intended recipient. This patient was receiving a decongestant and cough suppressant in place of his pain medication. He'd had what staff described as "a rough night." The man had terminal bone cancer, and for the past week was approaching the need for palliative care. His vital signs were normal, and he complained of pain on examination in his back and extremities. The staff was asked to contact his primary physician to explain the mistake in medication administration and see what dose of pain medication would be needed over the next 24 hours to re-establish pain control. Before the Attack One crew went back in service, the boarding home staff administered the MS Contin to the appreciative patient.

     For mixups in medication administration, remember to check both ends of the patient involvement!

Learning Point
     Accidental overdose with narcotic medications will result in a decrease in level of consciousness. The dose of naloxone needed to treat the patient is variable, and it must be administered judiciously to prevent complications of an immediate withdrawal.

Jim Augustine, MD, FACEP, serves on the clinical faculty in the Department of Emergency Medicine at Emory University, Atlanta, GA. He also serves as Medical Director for the Atlanta Fire Department, which includes operations at Hartsfield-Jackson Atlanta International Airport. He has served 23 years as a firefighter and EMT-A, and is a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.

Jim Augustine is a featured speaker at EMS EXPO, October 11-13, in Orlando, FL. For more information, visit www.emsexpo2007.com.