Monday, December 12, 2016

Carfentanil: A Dangerous New Factor in the U.S. Opioid Crisis

Carfentanil: A Dangerous New Factor in the U.S. Opioid Crisis

2 milligrams of
 Carfentanil powder next to
a penny.

Carfentanil is a synthetic opioid approximately 10,000 times more potent than morphine and 100 times more potent than fentanyl. The presence of carfentanil in illicit U.S. drug markets is cause for concern, as the relative strength of this drug could lead to an increase in overdoses and overdose-related deaths, even among opioid-tolerant users. The presence of carfentanil poses a significant threat to first responders and law enforcement personnel who may  come in contact with this substance. In any situation where any fentanyl-related substance, such as carfentanil, might be present, law enforcement should carefully follow safety protocols to avoid accidental exposure.
Officer & Public Safety Information
Carfentanil and other fentanyl analogues present a serious risk to public safety, first responder, medical, treatment, and laboratory personnel. These substances can come in several forms, including powder, blotter paper, tablets, patch, and spray. Some forms can be absorbed through the skin or accidentally inhaled. If encountered, responding personnel should do the following based on the specific situation:

Exercise extreme caution. Only properly trained and outfitted law enforcement professionals should handle any substance suspected to contain fentanyl or a fentanyl-related compound. If encountered, contact the appropriate officials within your agency.

Be aware of any sign of exposure. Symptoms include: respiratory depression or arrest, drowsiness, disorientation, sedation, pinpoint pupils, and clammy skin. The onset of these symptoms usually occurs within minutes of exposure.

Seek IMMEDIATE medical attention. Carfentanil and other fentanyl-related substances can work very quickly, so in cases of suspected exposure, it is important to call EMS immediately. If inhaled, move the victim to fresh air. If ingested and the victim is conscious, wash out the victim’s eyes and mouth with cool water.

Be ready to administer naloxone in the event of exposure. Naloxone is an antidote for opioid overdose. Immediately administering naloxone can reverse an overdose of carfentanil, fentanyl, or other opioids, although multiple doses of naloxone may be required. Continue to administer a dose of naloxone every 2-3 minutes until the individual is breathing on his/her own for at least 15 minutes or until EMS arrives.

Remember that carfentanil can resemble powdered cocaine or heroin. If you suspect the presence of carfentanil or any synthetic opioid, do not take samples or otherwise disturb the substance, as this could lead to accidental exposure. Rather, secure the substance and follow approved transportation procedures.
Carfentanil is used as a tranquilizing agent for elephants and other large mammals. The lethal dose range for carfentanil in humans is unknown; however, carfentanil is approximately 100 times more potent than fentanyl, which can be lethal at the 2-milligram range (photograph), depending on route of administration and other factors.
For additional safety information, please use the resources below:

CDC Health Advisory (#CDCHAN-00384);

CDC Health Update (#CDCHAN-00395);

DEA Fentanyl Warning Video;
2 milligrams of
powder next to
a penny

Friday, September 16, 2016


Interesting article from WSJ

Get your kids good and dirty

Get Your Children Good and Dirty
Researchers are discovering how crucial microbes are to our health and to avoiding a range of newly common diseases. So it’s time to get dirty, eat better and stop overusing antibiotics

By preventing babies and children from following their innate impulse to get dirty, we shield them from the microbial exposure that is essential for the development of a healthy immune system  By 
Updated Sept. 15, 2016 8:12 p.m. ET
Our friend Julia moved to a small free-range pig and poultry farm when her first child, Jedd, was a preschooler. When her second baby was born, she would strap him on her back every morning so that she could go to the chicken coop to pick up eggs. Jedd would chase and ride the chickens—and sometimes taste their feed and touch the fresh eggs. A couple of times, she even caught him chewing on something he had picked up from the ground.
At first, all of this caused Julia to freak out. But once she realized that Jedd wasn’t getting sick from these encounters with the chickens, she relaxed a bit. Her second child, Jacob, soon followed suit and never hesitated to get dirty on the farm. She once found him knee-deep in a cesspool of pig waste. Her early worries that her children were going to contract diseases from all this messiness dissipated, and she was pleased to see that they remained healthy.
Was Julia being an irresponsible parent—or might we all have something to learn from her example?
For most of the past century, we have considered microbes bad news, and for good reason: They cause disease, pandemics and death. Most human communities have experienced the benefits of medical advances like antibiotics, vaccines and sterilization, which have radically reduced the number and severity of infections that we suffer throughout life. Dying from a microbial infection is now a very rare event in the Western world, and, in the U.S., lifespans have increased by some 30 years since 1915—in large part because of success against infectious diseases.
Unfortunately, this progress has come with a price, as news reports have been telling us for some years now. Our anti-microbe mission has been accompanied, in industrialized countries, by an explosion in the prevalence of chronic noninfectious diseases and disorders. Diabetes, allergies, asthma, inflammatory bowel diseases, autoimmune diseases, autism, obesity and certain types of cancer are at an all-time high. The incidence of some of these disorders is doubling every 10 years, and they are starting to appear sooner in life, often in childhood.
All of these diseases have a genetic component, but their alarming growth cannot be explained by genetics alone. Recent studies find a direct link between the presence and absence of certain bacteria and all of the chronic diseases mentioned above. It turns out that the microbes within us are much more than quiet residents; they are an inherent part of our physiology, and altering them leads to disease.
Our own 2015 study(published in the journal Science Translational Medicine) found, for example, that 3-month-olds who had four particular microbes in their feces were much less likely to get asthma later in life. When those four microbes were introduced into mice, they protected against experimentally induced asthma, showing for the first time that alterations in gut microbes can drive the development of the disease. Lab experiments also have found that obese mice lose weight when they get a transfer of gut microbes from lean mice (and the reverse holds true as well, with lean mice growing fat after a transfer from obese mice).
The practical upshot of all this research is clear: Our health depends to a large degree on maintaining a robust and diverse community of microorganisms in our bodies—and establishing good gut-health as children is especially important.
During the first few months of life, the microbe community in our bodies is considerably less established and stable than later in life. Any drastic changes to it have a much higher chance of permanently altering our microbiota (as specialists call this world of tiny organisms within us) and our long-term health.
From the moment we are born, we begin getting colonized by bacteria, which kick-start a series of fundamental biological processes, including the development of our immune system. Before birth, the lining of our gut is full of immature immune cells. When bacteria move in, the immune cells react to them, changing and multiplying. They even move to other parts of the body to train other cells with the information they have acquired from these intruders. If deprived of this interaction, the immune system remains sloppy and immature, unable to fight off diseases properly.

Never before in human history have babies and children grown up so cleanly. Scientists haven’t figured out exactly how microbes do this at the molecular level, but we do know that most bacteria will teach these immune cells to tolerate them, whereas some bacteria—the pathogens that cause diseases—prompt strong resistance. The result is to make the intestine a relatively controlled and harmonious place.
Another fundamental function of microbes is to aid in the regulation of our metabolism. Like other animals, humans obtain energy from food that is digested and absorbed in the intestines. Besides helping us digest certain foods that the intestines can’t handle on their own, bacteria produce compounds that help to define how we use or store energy in our bodies. New research also shows that our microbiota plays an important role in neurological development and even in the health of our blood vessels.
Such discoveries have led scientists to call our microbiota a “new organ,” perhaps the last human organ to be discovered by modern medicine. Most of this knowledge is still relatively new and many pieces of the puzzle remain unsolved, but protecting the initial developmental stages of our microbiota clearly has a significant impact on our health.
Inflammatory diseases (such as asthma, allergies and inflammatory bowel disease) and metabolic diseases (such as obesity and diabetes) are characterized by alterations in our immune system and our metabolic regulation. Knowing what we do now about the role of the microbiota, it is not surprising that these diseases are being diagnosed in more children. They are, to a great extent, a consequence of relatively recent changes in our lifestyle—modern diet, oversanitization, excessive use of antibiotics—that have altered the specific microbes that affect our metabolism early on. We urgently need to find ways to modify our behavior so that our microbes can function properly.
Never before in human history have babies and children grown up so cleanly, and our diets have lost many of the elements most crucial to the health of our guts. We have become very bad hosts to our microbes.

Parents can promote good gut-health in their kids through diet. PHOTO: ISTOCK
What to do about it? The U.S. Food and Drug Administration took one helpful step earlier this month when it banned some chemicals used in antibacterial soap, but the most important changes need to take place in our everyday routines.
Parents can expose their children to an array of microbes by encouraging them to spend time outside, like our friend Julia on her farm (but not necessarily with chicken and pig waste). Today children spend much less time outside than they did only 20 years ago.
Babies and toddlers often aren’t allowed to play in the dirt or sand, and when they are, they are wiped clean immediately. Phrases like, “Yuck! Don’t play in the mud!” or “Don’t touch that bug, its dirty!” have become second nature.
We need to unlearn these habits. By preventing babies and children from following their innate impulse to get dirty, we shield them from the microbial exposure that is essential for the development of a healthy immune system.
Parents can also promote good gut-health in their kids through diet. It is well established that the Western diet—high in fats, sugars and highly refined grains—is very strongly associated with a number of diseases, especially obesity and the closely linked disease of type-2 diabetes.

Try nontraditional starchy vegetables such as sweet potatoes, parsnips or cassava. PHOTO:ISTOCK
Our ancestors grazed on a variety of foods, which ensured a variety of microbes in their intestines: Eating a range of different foods provides a hospitable environment for a range of different microbes. Today, 75% of the world’s food comes from just 12 plant species and five animal species. Amazingly, just three species—rice, corn and wheat—account for 60% of the calories that humans obtain from plants. Except for regions where a lack of economic development has preserved older farming and dietary practices, more people are eating refined white sugar, white flour and processed fats, instead of our ancestral diet of vegetables, fiber, fruit and nuts.
2010 study in the Proceedings of the National Academy of Sciences compared the microbiota of children living in rural Burkina Faso in West Africa to the microbiota of urban, city-dwelling children in Italy. The African children ate a high-fiber diet of vegetables, grains and legumes, with no processed foods, whereas the diet of the European children was full of sugars, animal fats and refined grains. The gut microbes of the children from Burkina Faso were very different from—and much more diverse than—those of the Italian kids.
We wouldn’t want to say that children in Burkina Faso have a healthier lifestyle than Italian children. They are more likely to suffer severe infections and malnutrition, and they have a lower life expectancy than children born in Western Europe. But they also have a decreased risk of suffering from the immune diseases that are epidemic in the Western world.

We should offer a variety of grains, including oats, rice, barley and quinoa PHOTO: ISTOCK
In an ideal world, children would harbor a rich and diverse community of microbes without the threat of severe infectious diseases, but our current practices only address half of this equation. Given how well bacteria respond to diet, eating a variety of foods is perhaps the best way to increase microbial diversity, and there’s no better time to do this than during the first few years of life.
As a practical matter, this means that we shouldn’t feed a baby only rice cereal for weeks until the package is finished. We should offer a variety of grains, including oats, rice, barley and quinoa. It’s also important to offer whole grains instead of refined ones. The Western diet is extremely low in fiber, and refined grains contain very little of it.
Protein-rich legumes, such as lentils, beans and peas, have an abundance of fiber and can be easily mashed for babies. Also try nontraditional starchy vegetables such as sweet potatoes, parsnips or cassava (tapioca) rather than just sticking to low-fiber veggies such as potatoes. For older children, add fermented foods, such as yogurt, kefir, sauerkraut and other pickled vegetables.

Protein-rich legumes, such as lentils, beans and peas, have an abundance of fiber and can be easily mashed for babies. PHOTO: ISTOCK
Most people in developed societies won’t crave these foods the same way that they crave the texture of macaroni and cheese or the like, but infancy is the best time to introduce good dietary practices. For children, eating healthy foods becomes a habit in the same way as cleaning their room does: by doing it frequently.
Food isn’t the only way that we have altered our microbiota, however. Our microbes have perhaps taken the biggest hit from one of the best things humanity has ever invented: antibiotics. These wonder drugs have saved millions of lives and will save millions more in the future.
But antibiotics aren’t targeted missiles that kill only the bad bacteria causing infections; they are carpet bombs that kill good and bad bacteria indiscriminately. Research now suggests a link between the use of antibiotics in early childhood and problems such as obesity, diabetes, asthma, allergies, autism and inflammatory bowel disease.

We ought to become more restrictive with the use of antibiotics in children.  We ought to become more restrictive with the use of antibiotics in children. Parents shouldn’t assume that all infections have to be treated with these drugs. Upper respiratory tract infections and colds are often caused by viruses, so antibacterials won’t cure them. Most sore throats, especially if the child also has a runny nose and cough, are caused by viruses and don’t need antibiotic therapy. If a child has a mild ear infection, it’s reasonable to watch and wait for a few days to see if it gets better on its own before starting antibiotic therapy. Also, parents should consider giving probiotic supplements (with live bacteria and yeasts) to a child if he or she is being given antibiotics.
With the scientific information now available, parents can make informed choices about helping their children to develop a thriving microbiota. We are still years away from learning the whole story of how microbes contribute to our physical well-being, but what we know today is pretty convincing evidence that they are crucial, especially early in life.
For much of the past century, we have ignored, and often destroyed, the microbes that keep us healthy. It’s time now to correct the balance.
Dr. Finlay is a microbiologist specializing in bacterial infections and the Peter Wall Distinguished Professor at the University of British Columbia. Dr. Arrieta is an assistant professor in the Department of Physiology and Pharmacology at the University of Calgary. This essay is adapted from their new book, “Let Them Eat Dirt: Saving Your Child From an Oversanitized World,” published by Algonquin Books of Chapel Hill.

Friday, August 5, 2016

Issues related to the use of Tourniquets on the Battlefield.

Clink on this link below to view an interesting article on tourniquet use. We all know that for the last 10 -15 years tourniquets have come back into protocol as the treatment of choice for severe hemorrhage that has failed to controlled by direct pressure and hemostatic gauze. In a hostile situation there might not be time or room to try homeostatic agents so a tourniquet might be the device of choice. This article, among other issues, examines the use of traditional 1 " wide tourniquets as compared to the newer pneumatic tourniquets. One issue identified was the difficulty in generating enough pressure on the average size male thigh to stop severe lower extremity hemorrhage. The other finding was that tourniquets wider than 1" accomplished hemorrhage control with less pressure and therefore had less tissue injury underlying the tourniquet. It seems that newer pneumatic tourniquets accomplished hemorrhage control quicker and with less complications compared to narrower 1 " tourniquets. Pneumatic tourniquets have been used extensively in orthopedic surgery so they have been well tested in regards to hemorrhagic control.  The issue, of course, is how hospital based devices will fare in more rugged conditions. The article mentions one particular device.  The Delpi Military Tourniquet.  See link below. 

The other issues examined was the loosening or removal of a tourniquet prior to surgery and the length of time before tourniquet application results in limb ischemia / damage. It seems that tourniquets applied for under 120 minutes do not result in any additional limb damage.  Removal or loosening is more conversational.  Protocols differ from region to region, so you must follow your regional protocol.  To this author it would seem reasonable to loosen a tourniquet that has achieved hemorrhage control if you are approaching the 120 minute mark and assess for resumption of bleeding.  If bleeding does not resume the tourniquet may remained loosened to prevent limb ischemia. Remember this is just a thought and does not constitute a treatment guideline.  You must always follow your protocols and Medical Directors guidelines. It would be rare in civilian prehospital emergency medicine to be with a patient who has had a tourniquet on for 120 minutes so the issue is probably not that pressing. Of course you might be performing a back county rescue, dealing with a lockdown / active shooter, or confined space situation so the issue should be addressed and protocols developed. 


Friday, July 22, 2016

K2 Epidemic - Synthetic Cannabinoids

Colorful packets of K2 and Spice.

What are synthetic cannabinoids?

Synthetic cannabinoids refer to a growing number of man-made mind-altering chemicals that are either sprayed on dried, shredded plant material so they can be smoked (herbal incense) or sold as liquids to be vaporized and inhaled in e-cigarettes and other devices (liquid incense). 
These chemicals are called cannabinoids because they are related to chemicals found in the marijuana plant. Because of this similarity, synthetic cannabinoids are sometimes misleadingly called "" (or "fake weed"), and they are often marketed as "safe," legal alternatives to that drug. In fact, they may affect the brain much more powerfully than marijuana; their actual effects can be unpredictable and, in some cases, severe or even life-threatening.

False Advertising

Synthetic cannabinoid products are often labeled "not for human consumption." Labels also often claim that they contain "natural" material taken from a variety of plants. However, the only parts of these products that are natural are the dried plant materials. Chemical tests show that the active, mind-altering ingredients are cannabinoid compounds made in laboratories.
Synthetic cannabinoids are included in a group of drugs called Synthetic cannabinoids are included in a group of drugs called "new psychoactive substances" (NPS). NPS are unregulated psychoactive (mind-altering) substances that have become newly available on the market and are intended to copy the effects of illegal drugs. Some of these substances may have been around for years but have reentered the market in altered chemical forms or due to renewed popularity.
Manufacturers sell these herbal incense products in colorful foil packages and sell similar liquid incense products, like other e-cigarette fluids, in plastic bottles. They market these products under a wide variety of specific brand names; in past years, K2 and Spice were common. Hundreds of other brand names now exist, such as Joker, Black Mamba, Kush, and Kronic.
For several years, synthetic cannabinoid mixtures have been easy to buy in drug paraphernalia shops, novelty stores, gas stations, and through the Internet. Because the chemicals used in them have a high potential for abuse and no medical benefit, authorities have made it illegal to sell, buy, or possess some of these chemicals. However, manufacturers try to sidestep these laws by changing the chemical formulas in their mixtures.
Easy access and the belief that synthetic cannabinoid products are "natural" and therefore harmless have likely contributed to their use among young people. Another reason for their use is that standard drug tests cannot easily detect many of the chemicals used in these products. 

How do people use synthetic cannabinoids?

Users usually smoke the dried plant material sprayed with synthetic cannabinoids. Sometimes they mix the sprayed plant material with marijuana, or they brew it as tea. Other users buy synthetic cannabinoid products as liquids to vaporize them in e-cigarettes.

How do synthetic cannabinoids affect the brain?

Synthetic cannabinoids act on the same brain cell receptors asdelta-9-tetrahydrocannabinol (THC), the mind-altering ingredient in marijuana.
So far, there have been few scientific studies of the effects of synthetic cannabinoids on the human brain, but researchers do know that some of them bind more strongly than marijuana to the cell receptors affected by THC, and may produce much stronger effects. The resulting health effects can be unpredictable.
Because the chemical composition of many synthetic cannabinoid products is unknown and may change from batch to batch, these products are likely to contain substances that cause dramatically different effects than the user might expect.
Synthetic cannabinoid users report some effects similar to those produced by marijuana:
  • elevated mood
  • relaxation
  • altered perception—awareness of surrounding objects and conditions
  • symptoms of psychosis—delusional or disordered thinking detached from reality
Blurred night view of the city with distorted streaks of colored lights.Foto, ©
Psychotic effects include:
  • extreme anxiety
  • confusion
  • paranoia—extreme and unreasonable distrust of others
  • hallucinations—sensations and images that seem real though they are not

  • What are some other health effects of synthetic cannabinoids?
    People who have used synthetic cannabinoids and have been taken to emergency rooms have shown severe effects including:
    • rapid heart rate
    • vomiting
    • violent behavior
    • suicidal thoughts
    Synthetic cannabinoids can also raise blood pressure and cause reduced blood supply to the heart, as well as kidney damage and seizures. Use of these drugs is associated with a rising number of deaths. 

    Are synthetic cannabinoids addictive?

    Teenage boy looking depressed.Foto, Humannet/©Shutterstock
    Yes, synthetic cannabinoids can be addictive. Regular users trying to quit may have the following withdrawal symptoms:
    • headaches
    • anxiety
    • depression
    • irritability
    Behavioral therapies and medications have not specifically been tested for treatment of addiction to these products. 

    Points to Remember

    • Synthetic cannabinoids refer to a growing number of man-made mind-altering chemicals sprayed on dried, shredded plant material or vaporized to get high.
    • Synthetic cannabinoids are sometimes misleadingly called "synthetic marijuana" (or "fake weed") because they act on the same brain cell receptors as delta-9-tetrahydrocannabinol, the mind-altering ingredient in marijuana.
    • The effects of synthetic cannabinoids can be unpredictable and severe or even life-threatening.
    • The only parts of synthetic cannabinoid products that are "natural" are the dried plant materials. Chemical tests show that their active ingredients are man-made cannabinoid compounds.  
    • Synthetic cannabinoid users report some effects similar to those produced by marijuana:
      • elevated mood
      • relaxation
      • altered perception
      • symptoms of psychosis
    • Synthetic cannabinoids can also cause serious mental and physical health problems including:
      • rapid heart rate
      • vomiting
      • violent behavior
      • suicidal thoughts
    • Synthetic cannabinoids can be addictive.
    • Behavioral therapies and medications have not specifically been tested for treatment of addiction to these products.
  • Treatment Overview:
         1)  For mild and moderate toxicity, treatment consists
             primarily of supportive care. Most patients do not
             require any specific treatment and, especially with an
             inhalational exposure, symptoms should resolve in a few
         1)  Treatment is symptomatic and supportive. Administer
             benzodiazepines for agitation or delirium. Consider
             diphenhydramine for dystonia or rigidity. SEIZURES:
             Initially treat with benzodiazepines, add propofol or
             barbiturates if seizures persist. Airway support as
             needed. TACHYCARDIA: In agitated patients, tachycardia
             usually responds to benzodiazepine sedation. Obtain a
             baseline ECG and institute continuous cardiac
             monitoring. CHEST PAIN: Myocardial infarction has been
             reported in adolescents abusing THC homologs. Perform
             serial ECGs, institute continuous cardiac monitoring
             and obtain serial troponin concentrations. Treat with
             aspirin, nitroglycerin and benzodiazepines. ABSTINENCE
             SYNDROME: Abrupt discontinuation of chronic use can
             cause profuse sweating, tremors, palpitations,
             insomnia, headache, depression, diarrhea, nausea, and
             vomiting. Treat with benzodiazepines.
         1)  Abrupt discontinuation of chronic use can cause profuse
             sweating, tremors, palpitations, insomnia, headache,
             depression, diarrhea, nausea, and vomiting. Treat with
         1)  Primary route of exposure is via inhalation;
             gastrointestinal decontamination is not necessary even
             if these substances are ingested.
         1)  Rarely necessary, but perform early if life-threatening
             cardiac dysrhythmias, significant agitation/delirium or
             seizures develop.
        F)  ANTIDOTE
         1)  None.
        G)  DELIRIUM
         1)  Treat agitation/delirium in patients with suspected
             exposure to THC homologs with oral or IV

Wednesday, July 20, 2016

Pelvic Fractures

Pelvis Fractures
The pelvis is a ring-like structure of bones at the lower end of the trunk. The two sides of the pelvis are actually three bones (ilium, ischium, and pubis) that grow together as people age. Strong connective tissues (ligaments) join the pelvis to the large triangular bone (sacrum) at the base of the spine. This creates a bowl-like cavity below the rib cage. On each side, there is a hollow cup (acetabulum) that serves as the socket for the hip joint.
Many digestive and reproductive organs are located within the pelvic ring. Large nerves and blood vessels that go to the legs pass through it. The pelvis serves as an attachment point for muscles that reach down into the legs and up into the trunk of the body. With all of these vital structures running through the pelvis, a pelvic fracture can be associated with substantial bleeding, nerve injury, and internal organ damage.


Trauma patients who present with unstable pelvic fractures have sustained a high energy injury that is commonly associated with disruption of arteries and veins resulting in major hemorrhage. Patients with pelvic fractures who present in shock have a mortality of 30-50%. When combined with injuries in other body regions such as the abdomen, the mortality rises even higher, approaching 100% in some series. However a systematic multidisciplinary approach to these injuries, directed initially only at hemorrhage control, can lead to significant improvements in survival.

Key Points

Pelvic Injury

  • An unstable pelvic injury with signs of shock should be treated as a vascular injury.
  • Hemorrhage may be from fractured bone and disrupted veins and arteries.
  • High energy trauma is associated with multi-cavity injury, and there may be hemorrhage in the chest or abdomen as well as the pelvis and long bones.


  • A multidisciplinary approach is essential. All team members must know their roles and key decisions.
  • Appropriate resuscitation maneuvers are as important as hemorrhage control interventions.
  • Management of massive transfusion, coagulopathy and hypothermia are vital for success.
  • damage control approach should be adopted for all these patients: do the minimum necessary to save life.

Tuesday, July 19, 2016

Potential dangerous side effects with the over administration or rapid administration of Naloxone.

While Naloxone has been proven to be an effective treatment in the patients suffering from respiratory depression secondary to Opioid use; there is a growing and troubling number of reports of potentially life threatening side effects with excessive dosing or rapid administration of Naloxone. 

It has been well documented that patients receiving Naloxone may experience symptoms of Opioid withdrawal. These symptoms may include: nausea, vomiting, headache and irritability.  

The administration of high-dose Naloxone and/or rapidly infused Naloxone may cause catecholamine release and consequently pulmonary edema, hypertension, and cardiac arrhythmia. These risks warrant the cautious use of Naloxone and adequate monitoring of the cardio-respiratory status of the patient after Naloxone administration is indicated. 

The best treatment is prevention. Administer Naloxone slowly and give it 1-3 minutes to be absorbed. If your patient's respiratory status is poor use the BVM to support ventilations until the Naloxone begins to work.  

Remember that Naloxone has a short half life so it may be necessary to administer a 2nd dose if you are still with your patient after 20 to 30 minutes and they show signs of the Naloxone losing its reversal effects. 

Friday, May 13, 2016


Have you heard of dabbing? Dubbed the "crack of pot,” dabbing is a form of consuming highly concentrated marijuana in a vaporized form and has been described as freebasing marijuana in popular media outlets. Once an underground practice, this dangerous trend has gained popularity in recent months and could change the culture of marijuana use. 
What is dabbing?
Dabbing allows the user to ingest a high concentration of Tetrahydrocannabinol (), the psychoactive ingredient in marijuana. Butane Hash Oil (BHO), an oil or wax-like substance extracted from the marijuana plant, is placed on a “nail” attached to a specialized glass bong called a “rig.” A blow torch is used to heat the wax, which produces a vapor that can then be inhaled. This ingestion method means the effects of dabbing can be felt instantaneously.
A practice related to dabbing includes placing hash oil in vaping devices, which look like e-cigarettes and don’t emit any smoke. This decreases opportunities to get caught using hash oil, and gives middle and high school aged youth the opportunity to get high in increasingly public places, even at school.
Popularity with inhaling hash oil is increasing because it is the fastest way to get an intense high. Smoking a tic-tac sized drop of BHO, or “hash oil,” is equivalent to two or three typical sized portions of marijuana hitting the system all at once.
In some states you can buy hash oil at medical marijuana dispensaries. Other states have black market services that deliver the hash oil right to your door. When all else fails, people can make it themselves using flammable solvents such as alcohol or butane, which can lead to explosions and serious injuries. Step-by-step instructions with pictures and videos are available online and only require a quick Google search. The ability of teens to easily access the supplies and information needed for dabbing is a cause of great concern.
Dangers of dabbing
Making hash oil may be one of the most dangerous aspects of dabbing. BHO is extracted by blasting butane, also known as lighter fluid, through the marijuana plant.
There have been increasing news reports of houses and apartment buildings exploding as a result of the extraction process, leaving individuals in need of skin grafts and reconstructive surgery for severe burns, broken bones or can even lead to death. The increase in explosions was severe enough for the Federal Emergency Management Agency (FEMA) to issue a special warning about the dangers of manufacturing hash oil. As of November 2014, the Los Angeles Division of the Drug Enforcement Administration (DEA) confirmed 49 explosions nationwide related to marijuana extraction. In addition, contaminants in the hash oil, including butane and other neurotoxins, can lead to serious allergic reactions and even poisonings.Dabbing comes with a slew of negative side effects, including a rapid heartbeat, blackouts, feeling like something is crawling under the skin, loss of consciousness and psychotic symptoms, including paranoia and hallucinations.
As this trend grows, more YouTube videos are being uploaded by teens chronicling their dabbing experiences. These videos showcase teens dabbing for the first time or experimenting with higher and higher doses trying to outdo their peers on the Internet. Many of these videos feature the individuals falling out of chairs, unable to move on their own and pleading with their friends to call for medical assistance.
What we still don’t know about dabbing
Most research on marijuana has been conducted with much lower concentrations of THC than what is found in BHO. Research already shows that smoking marijuana is harmful for teens. While a typical marijuana joint has 15 percent THC, reports suggest that hash oils can have THC concentration levels as high as 60-90 percent.
We do know that marijuana can be addictive, especially for those who begin experimenting at younger ages. A preliminary study found that people who report daily use of marijuana and occasional dabbing have a harder time cutting back or quitting, need to use more of the substance to get the same effect and find it difficult to switch back to smoking marijuana with lower THC concentrations.
As more states legalize medical or recreational marijuana, it appears likely that dabbing will become more widespread among teens. It is important that parents understand the dangers and know the warning signs so they can intervene if needed.

Sunday, March 13, 2016

Herion laced with Xylazine

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Attached is information that the HVREMS put out last Friday; forwarded to them by the Susquehanna Regional office. I did a quick look online and this does not seem to be a new issue, but it may be new to our area.

Naloxone would still be effective in reversing the Opioid, but the patient may remain in respiratory depression / arrest from the Xylazine.  Management for this would be to support ventilations. There is a higher incident of cardiac arrest due to Xylazine negative chronotropic effect and a decrease in cardiac contractility.    If anyone has any experience with managing this type of patient please let me know.

Click on  the link below for more information:

Link to article


Wednesday, August 5, 2015

FDA Advisory on Heartmate and Heartware LVADS

Please see the FDA advisory below. The advisory seems to indicate that the rate of complications from bleeding and embolic events is higher in  actual use than it was during the clinical trials. Both events are known complications of LVAD use.  Since there is no alternative for the patient with a severely damaged left ventricle LVADS will continued to be utilized, but these issue will be more carefully studied.

For the complete advisory click on this link.



Serious Adverse Events with Implantable Left Ventricular Assist Devices (LVADs): FDA Safety Communication

Date Issued: August 5, 2015
  • Health care providers treating heart failure patients
  • Patients with a LVAD
  • Caregivers of patients with a LVAD
Specialties: Cardiology, Cardiac Surgery, Heart Failure, Heart Transplantation
Implantable LVADs help the left ventricle (the main pumping chamber of the heart) circulate blood throughout the body in patients with advanced heart failure. The devices consist of a blood pump, power pack and controller. The blood pump is implanted inside a patient’s body and attached to the heart’s left ventricle and to the aorta. The power pack and controller are connected to the blood pump and carried by the patient outside the body.
LVADs are approved for bridge-to-transplant (BTT) or destination therapy (DT). BTT refers to providing circulatory support to a patient at risk of imminent death from non-reversible left ventricular heart failure until a donor heart becomes available for a heart transplant. DT refers to providing circulatory support to a patient with end-stage left ventricular heart failure who is not candidate for a heart transplant.
To date, there are two implantable LVADs approved by the FDA:
  • The HeartMate II Left Ventricular Assist System manufactured by Thoratec Corporation, approved for BTT in 2008 and DT in 2010 and
  • The HeartWare Ventricular Assist System HVAD manufactured by HeartWare, Inc., approved only for BTT in 2012.
Purpose: The FDA is alerting health care providers, patients, and caregivers about serious adverse events associated with LVADs. These adverse events include an increased rate of pump thrombosis (blood clots inside the pump) with Thoratec’s HeartMate II and a high rate of stroke with the HeartWare HVAD since approval of the devices. We are also aware of bleeding complications associated with both devices.
Summary of Problem and Scope:
The FDA is aware of serious adverse events associated with both devices.
Thoratec HeartMate II:
The FDA has received reports and information from a variety of sources indicating an increase in the rate of pump thrombosis events in patients implanted with the HeartMate II. Information also shows that patients are experiencing pump thrombosis events earlier than observed during the clinical trials conducted to support the product’s approvals in 2008 (BTT) and 2010 (DT). For example, two analyses in the scientific literature reported the confirmed (after explant) HeartMate II pump thrombosis rate as high as 8.4% of implanted devices at 3 months (Starling et al, 2013) and 6% of implanted devices at 6 months (Kirklin et al, 2014). This is compared to 1.6% of implanted devices at one year during the BTT clinical trial and 3.8% of implanted devices at 2 years during the DT clinical trial.
Pump thrombosis is a serious complication that can require repeat surgery to replace the pump or can lead to death.
HeartWare HVAD:
The FDA is aware of recently reported results from a clinical trial designed to evaluate the safety and effectiveness of the HeartWare HVAD when used for the DT indication. Investigators reported 28.7% of HVAD patients experienced one or more strokes over two years, compared to 12.1% among patients implanted with the control device (HeartMate II). Although the HVAD is not currently approved for DT, it is the same device approved for the BTT indication.
Stroke is a serious complication that can lead to permanent patient disability and death.
Thoratec HeartMate II and HeartWare HVAD:
The FDA is aware of bleeding complications related to both the Thoratec HeartMate II and HeartWare HVAD, through adverse event reports and information from a variety of sources. The cause of bleeding complications is not fully understood, but is likely due to many different factors. One possible factor may be modification to blood thinning (anticoagulation) therapy in an attempt to lower the risks of pump thrombosis and embolic stroke.
Bleeding is a serious complication that can lead to death.
The FDA recognizes that LVADs are life-sustaining, life-saving devices for patients with advanced left ventricular heart failure. When used for the currently approved indications in appropriately selected patients, we believe the benefits of these LVADs continue to outweigh the risks. However, the FDA also believes it is important for health care providers and patients to be aware of this important information when considering the use of these devices and clinical management of their patients.
Health Care Providers:
  • Perform a thorough clinical evaluation, assessing the benefit-risk profile of each patient in determining the most appropriate treatment plan and, if necessary, selecting a device.
  • Consider the risks for pump thrombosis, stroke, and bleeding when determining the appropriate therapy for individual patients.
  • Review the current device labeling prior to making treatment decisions if you are considering using either of these devices.
  • Return all explanted LVAD devices and components to their respective manufacturer. In the case of LVAD-related pump thrombosis and other adverse events, manufacturer evaluation of the affected device is critical to better understand the reasons for these adverse events.
  • Discuss openly and in detail the benefits and risks of any therapy being considered by your heart failure specialist, cardiologist and surgical team. This discussion should include:
    • your risks of developing an adverse event like a blood clot or stroke and the potential side effects if you do experience an adverse event.
    • how the benefits and risks of the device compare to other non-LVAD medical therapies.
  • If you have any concerns regarding your device, discuss them with the health care providers managing your heart failure.
FDA Actions:
Thoratec HeartMate II:
The FDA has extensively evaluated all available information, including adverse event reports received by FDA, data from Thoratec, data from the scientific literature, and data from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). Our analysis did not identify discrete, device-specific reasons for the reported rise in pump thrombosis. The FDA acknowledges the risks of pump thrombosis for HeartMate II have increased since the time of approval. However, careful review of all available data suggests the benefits of the device, when used in appropriately selected patients, continue to outweigh the risks for the currently approved indications.
The FDA has been working with Thoratec to better understand and explain the increased incidence of pump thrombosis. On August 5, 2014, the FDA approved updated labeling for the HeartMate II that includes the risk of pump thrombosis.
Thoratec is currently conducting a prospective, multi-center, non-randomized study designed to assess the incidence of HeartMate II pump thrombosis and to identify the risk factors associated with pump thrombosis events. Details of this study can be found on the National Institutes of Health website:
HeartWare HVAD:
The FDA is concerned about the reported stroke rates but at this time, believes the benefits of using the device continue to outweigh the risks for the currently approved BTT indication. The FDA also believes it is appropriate to continue the clinical investigation of this device in the DT population with the careful monitoring procedures currently in place. The FDA continues to evaluate all available information, including adverse event reports received by FDA, data from HeartWare, data from the scientific literature, and data from INTERMACS for the currently approved BTT indication, as well as the data from the DT clinical trial. As more information about the risks associated with the device becomes available, the FDA will work with HeartWare to identify any future actions that may be appropriate.
HeartWare is currently conducting a prospective, randomized, controlled, un-blinded, multi-center study to assess whether optimal blood pressure management can help lower the incidence of stroke in DT patients implanted with an HVAD. Details of this study can be found on the National Institutes of Health website:
Reporting Problems to the FDA:
Prompt reporting of adverse events can help the FDA identify and better understand the risks associated with LVADs.
If you suspect or experience a problem with an LVAD, we encourage you to file a voluntary report through MedWatch, the FDA Safety Information and Adverse Event Reporting program. Health care personnel employed by facilities that are subject to FDA's user facility reporting requirements should follow the reporting procedures established by their facilities.
Additional Resources: