1. Naloxone (Narcan) Induced Pulmonary Edema
John Cunha, DO, FACOEP
Holy Cross Hospital
Oakland Park EMS Medical Director

2. Naloxone (Narcan) Use
Used to reverse the respiratory depression effects of opioids
Dosed from 0.4mg-4mg per dose depending on the patient’s response
Given in small doses until patient’s respiratory rate increases

3. Naloxone (Narcan) Major Side-effects
Hypertension
Ventricular arrhythmias
Cardiac arrest
Seizures
Pulmonary edema

4. Flash Pulmonary Edema Extremely rare event
First reported in anesthetized lab animals
Seems to be related to higher doses of Narcan given and rapidity of reversal
IV infusion may be more likely to precipitate rapid reversal and side-effects

5. Flash Pulmonary Edema-SIGNS
Sudden dropping O2 sat
Tachypnea
Hypertension (could be followed by hypotension)
Feeling of Shortness of Breath
Rales throughout lung fields

6. Flash Pulmonary Edema-WHY?
In opiate dependent patients, naloxone causes catecholamine (epinephrine) release leading to pulmonary edema
The mechanisms for the increase in epinephrine following the administration of naloxone include its direct antagonizing effects on mu-opioid receptors
Sudden overwhelming drug withdrawal symptoms-causing “Fight or Flight”

7. Flash Pulmonary Edema-WHY?
Increases in plasma concentrations of epinephrine by 30-fold—“Fight or Flight”
HUGE Increases in Cardiac Output
Increases in blood pressure and heart rate
The above hemodynamic effects appeared to be more pronounced if the baseline PCO2 was elevated (Patients with longer downtime)

8. Flash Pulmonary Edema-WHY?
In the lung tissue epinephrine leads to leaking of pulmonary capillaries
This leads to accumulation of pulmonary fluid (Rales on auscultation)
May also be related to the release of histamine within the lung tissue
Secondary to the epi or the opioid itself
This is the edema

9. Flash Pulmonary Edema-SIGNS
Sudden dropping O2 sat
Tachypnea
Hypertension (could be followed by hypotension)
Feeling of Shortness of Breath
Rales throughout lung fields

10. What to do??? Ensure adequate oxygenation and ventilation
Give narcan in small frequent doses until respiratory depression is reversed
High flow oxygen
Nitroglycerin 0.4mg SL if no hypotension (repeat per protocol)
Lasix 20 mg IV if no hypotension (If available)
Administer CPAP with 10 cm H2O PEEP (medical procedure 4.12)
Intubate if necessary

11. SOURCES
Florida Regional Common EMS Protocols
Chest, Oct. 2007, Vol. 132, No. 4