Cardiac arrest naloxone

Only six of 36 children who took overdoses of co-phenotrope had signs of atropine overdose (central nervous system excitement, hypertension, fever, flushed dry skin) (1). Opioid overdose (central nervous system and respiratory depression with miosis) predominated or occurred without any signs of atropine toxicity in 33 cases (92%). Diphenoxylate-induced hjrpoxia was the major problem and was associated with slow or fast respiration, hypotonia or rigidity, cardiac arrest, and in three cases cerebral edema and death. Respiratory depression recurred 13-24 hours after the ingestion in seven cases and was probably due to accumulation of difenoxine, an active metabolite of diphenoxylate. Recommended treatment is an intravenous bolus dose of naloxone, followed by a continuous intravenous infusion, prompt gastric lavage, repeated administration of activated charcoal, and close monitoring for 24 hours. 

Patients with pre-existing cardiac abnormalities are particularly susceptible to effects such as hypertension, pulmonary edema, atrial and ventricular dysrhythmias, and cardiac arrest, which can occur when naloxone is given to reverse opioid effects. 

A 2-month-old boy had a cardiac arrest when he was given a combination of pethidine, promethazine, and chlorpromazine in 10 times the recommended dose by the wrong route (intravenously rather than intramuscularly). Within seconds he became apneic and stiff. Cardiopulmonary resuscitation was instituted, including two intravenous doses of adrenaline 0.06 mg and naloxone 0.6 mg, with recovery 7 minutes after the incident and complete resolution 24 hours later. 

Cardiovascular Cardiac arrest occurred in a preterm neonate (gestation 27 weeks) after a bolus of naloxone (100 micrograms/kg) for the treatment of a 10-fold morphine... 

Deshpande G, Gill A. Cardiac arrest following naloxone in an extremely preterm neonate. Eur J Pediatr 2009 168(1) 115-7. 

DEATH A 13-month-old child developed respiratory and cardiac arrest after ingestion of a single tablet of buprenorphine/naloxone (8mg/2 mg) [87 ]. Subsequent autopsy showed elevated serum and gastric concentrations of buprenorphine. Parenteral abuse of buprenorphine/naloxone (insufflation or intravenous injection) has lead to several deaths in Finland. Of the 225 fatalities due to buprenorphine, 8.4% were due to buprenorphine/ naloxone [88 ]. 

Patients who are acutely intoxicated with an opioid usually present with miosis, euphoria, slow breathing and slow heart rate, low blood pressure, and constipation. Seizures may occur with certain agents such as meperidine (Demerol ). It is critically important to monitor patients carefully to avoid cardiac/ respiratory depression and death from an excessive dose of opioids. One strategy is to reverse the intoxication by utilizing naloxone (Narcan ) 0.4 to 2 mg IV every 2 to 3 minutes up to 10 mg. Alternatively, the IM/SC route may be used if IV access is not available. Because naloxone is shorter-acting than most abused opioids, it may need to be readministered at periodic intervals otherwise the patient could lapse into cardiopulmonary arrest after a symptom-free interval of reversed... 

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