Recurrent opioid toxicity after pre-hospital care of presumed heroin overdose patients.

BACKGROUND: In patients with presumed heroin overdose, the recommended time of observation after reversing heroin toxicity with naloxone varies widely. The aims of this study were to examine the incidence of recurrent opioid toxicity and the time interval in which it occurs after pre-hospital treatment in presumed heroin overdose patients. METHODS: We undertook a retrospective study in Helsinki (population, 560,000). Records were reviewed from 1 January 1995 to 31 December 2000. Patients included were treated by the emergency medical service (EMS) for a presumed heroin overdose. Patients with known polydrug/alcohol use or the use of opioids other than heroin were excluded. The EMS records were compared with the cardiac arrest database and the medical examiners' records. RESULTS: One hundred and forty-five patients were included. The median dose of pre-hospital administered naloxone was 0.4 mg. After pre-hospital care, 84 patients refused further care and were not transported to an emergency department (ED). Seventy-one received pre-hospital naloxone, and no life-threatening events were recorded during a 12-h follow-up period in these patients. After pre-hospital care, 61 patients were transported to an ED. Twelve patients received naloxone in the ED for respiratory depression. All had signs of heroin use-related adverse events within 1 h after receiving pre-hospital naloxone. CONCLUSIONS: Allowing presumed heroin overdose patients to sign out after pre-hospital care with naloxone is safe. If transported to an ED, a 1-h observation period after naloxone administration seems to be adequate for recurrent heroin toxicity.

Outcome after heroin overdose and cardiopulmonary resuscitation.

BACKGROUND: The survival of heroin overdose patients resuscitated from cardiac arrest is reported to be poor. The aim of our study was to investigate the outcome and characteristics of survivors after cardiac arrest caused by heroin overdose. METHODS: This was a retrospective study in a medium-sized city (population, 560,000). Between 1 January 1997 and 31 December 2000, there were 94 combined cardiac arrests caused by acute drug poisonings. The main outcome measure was survival to discharge. RESULTS: Cardiopulmonary resuscitation was attempted in 19 heroin overdose patients (group A) and in 53 patients with cardiac arrest caused by other poisonings (group B). Three (16%) vs. six (11%) patients were discharged alive (group A vs. B, respectively). The survivors in group A had an Emergency Medical Service (EMS)-witnessed cardiac arrest or the Emergency Dispatching Centre was called before the arrest occurred. There was no statistically significant difference between the two groups in terms of survival. Survivors in both groups suffered from acute renal failure (two), hypoglycaemia (four) and hypothermia (three). CONCLUSION: Survival after cardiac arrest caused by heroin overdose is possible if the arrest is EMS witnessed or the Emergency Dispatching Centre is called before the cardiac arrest occurs. In comparison with cardiac arrests caused by other poisonings, there was no difference in survival. The incidence and mechanism of hypoglycaemia should be examined in further studies.

Undiagnosed amyotrophic lateral sclerosis and respiratory failure.

Two patients suffering from exacerbation of chronic respiratory insufficiency due to previously undiagnosed amyotrophic lateral sclerosis are reported. Both patients had a false diagnosis of asthma with a restrictive component. The diagnosis had been made after pulmonary function studies, and both patients had also received treatment for asthma. A central etiology was suspected when weaning from mechanical ventilation proved unsuccessful during respiratory failure, necessitating intensive care. A neurologic examination and a typical electroneuromyography recording confirmed the diagnosis of amyotrophic lateral sclerosis. Neuromuscular disorders must be excluded when treating patients with respiratory failure, even if they already have the diagnosis of chronic pulmonary disease.