Dr. McKeowns References

 

Another health care providers response italics 2nd Response

Chief Medical Officer Dr. David McKeown Nov 25, 2015 Quote “Attached are the references used to develop the TPH Naloxone protocol. Thank you for your interest in this issue. As previously indicated we will not be revising our protocol.” Program started Aug 31, 2011. I was one of the first to take this training said to myself ‘This will take a week to clear up, dirt has got more brains’  Development and implementation of an opioid overdose prevention and response program in Toronto, Ontario

My letter Emergency Medicine News Dec. 2015  

START OF DR. McKeown’s REFERENCES 

1. Becker LB, Berg RA, Pepe PE, Idris AH, Aufderheide TP, Barnes TA, et al. A reappraisal of mouth-to-mouth ventilation during bystander-initiated cardiopulmonary resuscitation. A statement for healthcare professionals from the Ventilation Working Group of the Basic Life Support and Pediatric Life Support Subcommittees, American Heart Association. Resuscitation 1997 Nov;35(3):189-201.

My response: This was the research on chest compressions only specific to sudden witnessed cardiac arrest, because the blood is still oxygenated.  This became practice in the 2010 guidelines.  Respiratory emergencies remain the same rescue breathing.

2nd Response: Quotes: “… this report … is not intended to change any current AHA recommendations or guidelines for performance of CPR.” “It is important to emphasize that this report makes no changes in current AHA CPR guidelines and to consider why no changes are warranted.” “.… this is a limited subpopulation of cardiopulmonary arrests and is not applicable to many resuscitations, such as those conducted for children, victims of submersion, respiratory failure, and many other arrest types.” “It is also important to note that the current discussion and available research focus only on the contribution of mouth-to-mouth ventilation in the setting of sudden adult fibrillatory cardiac arrest.  If a delay in mouth-to-mouth ventilation is being considered, the overall net impact on the public for saving lives from all causes of arrest, not merely sudden fibrillatory circulatory arrest, must also be taken into account.”

2.  Borgbjerg FM, Nielsen K, Franks J. Experimental pain stimulates respiration and attenuates morphine-induced respiratory depression: a controlled study in human volunteers. Pain 1996 Jan;64(1):123-128.

See training literature with permission Toronto Public Health   (Slide 10)  “Do NOT: slap to hard, kick them in the testicles, burn the bottom of their feet Why not? Could cause serious harm”  “Do NOT: let them sleep it off  Why not?  could stop breathing and die”

My response:  Ever been punched in the chest or stomach makes it hard to breathe. Our breathing is controlled by our diaphragm adult needs 1.5 liters of air every 5 seconds to our alveoli sacs in lungs to stay alive.

2nd Response:  This is a very small study of 10 healthy male-only volunteers ranging between 31 and 38 years of age.  It is not a randomized study.  There is no comparison with rescue breathing.  It did not involve pain inflicted to the chest via chest compressions, rather pain was induced via a pneumatic cuff on the calf. On top of the glaring fact that pain via chest compressions would just as likely interfere with breathing rather than assist it, this study tells you nothing whatsoever about the value of chest compressions versus rescue breathing in response to opioid overdose. This Naloxone Training Guide, of August 2014, adapted with permission from: Toronto Public Health’s POINT program & Ottawa’s Public Health’s POPP program, warns on page 10, : “HOW NOT TO RESPOND TO AN OVERDOSE: Do NOT: Slap to hard, kick them in the testicles, burn the bottom of their feet. Why not? Could cause serious harm.” In Complications of cardiac resuscitation, Atcheson SG, Fred HL.  (American Heart Journal 1975;89(2):263-65), it is warned that chest compressions are a drastic measure that should only be preformed on a cardiac arrest patient.  Also, see the table on page 264.

complicationA2

3. Eberle B, Dick WF, Schneider T, Wisser G, Doetsch S, Tzanova I. Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse. Resuscitation 1996 Dec;33(2):107-116.

My response:  No need to check for pulse Public Health Ontario’s signs of overdose proves your heart is beating, and in need of immediate rescue breathing.  Public Health’s Naloxone Training  Listen 9:20 secs signs of respiratory emergency.  My copy above video with comments

2nd Response:  This study was intended to “develop a methodology to study diagnostic accuracy in detecting the presence or absence of the carotid pulse in unresponsive patients, and (2) to evaluate diagnostic accuracy and time required by first responders to assess the carotid pulse”, and the authors studied accuracy in the setting of coronary artery bypass grafting.  It tells you nothing whatsoever about the value of chest compression’s versus rescue breathing in response to opioid overdose. The POINT program is specifically an overdose response program, designed to teach appropriate response to a life-threatening respiratory emergency in which the patient could die at any second from lack of oxygen rather than from cardiac arrest, and the recognisable signs of overdose are well-established.  Furthermore, we know that over a million respiratory patients present to hospital in Ontario per year, compared to only 7,000 out of hospital sudden witnessed cardiac arrests. The above study provide no justification whatsoever for the use of chest compression’s rather than rescue breathing in response to an opioid overdose.

 4. Kleinman ME, Brennan EE, Goldberger ZD, Swor RA, Terry M, Bobrow BJ, Gazmuri RJ, Travers AH, Rea T. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S414–S435

Article quote:  “Sudden cardiac arrest remains a leading cause of death in the United States” [few are out of hospital sudden witnessed cardiac arrest per year in Ontario.  More than a million people presented to Ontario hospitals with a respiratory emergency per year]

15,000 out of hospital cardiac arrests per year Ontario a lot less sudden witnessed https://www.ices.on.ca/Newsroom/News-Releases/2014/Survival-rates-improving-for-out-of-hospital-cardiac-arrest-patients

My response: Respiratory emergencies are always dealt with in a different section of the guidelines, because breathing emergency is a different matter than cardiac arrest. This is dealing with sudden cardiac arrest, not acute respiratory failure poisoning (drug OD).  ARTICLE IS FROM 2015,  BASING PUBLIC HEALTH’S PROTOCOL ON A FUTURE ARTICLE??

2nd Response:  This is Part 5, which deals with sudden cardiac arrest, not respiratory emergencies. See 2015 AHA Guidelines, Part 10, page 501, third paragraph: it refers you to the 2010 guidelines, Part 12:7 toxic ingestions. Furthermore, the 2010 AHA Guidelines state that “Naloxone has no role in the management of cardiac arrest.” Also, the above Guideline is from 2015, fours years after Toronto Public Health launched the POINT program, and could not have been part of any “extensive literature review” performed prior to Dr. McKeown’s approval of, or implementation of, the program.

5. Lavonas EJ, Drennan IR, Gabrielli A, Heffner AC, Hoyte CO, Orkin AM, Sawyer KN, Donnino MW. Part 10: special circumstances of resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015;132(suppl 2):S501–S518

Quote page 501 third paragraph refers you to the 2010 guidelines Part 12:7  quote “Rescue breathing, then you may give Naloxone continue rescue breathing” “Naloxone has no role in the Management of cardiac arrest”  http://circ.ahajournals.org/content/132/18_suppl_2/S501.full

Article quotes “should support ventilation and administer naloxone to patients”  “Bag-mask ventilation [rescue breathing same italics mine] should be maintained until spontaneous breathing returns”

Page 506  Full CPR and Naloxone???  Response: Naloxone has no role in the management of the dead, heart is not beating therefore no blood pumping Naloxone to brain.

2nd Response: This protocol deals with cardiac arrest rather than respiratory emergency (and, interestingly, includes full rescue breathing CPR, rather than chest compressions only). Page 501, third paragraph, refers you to the 2010 AHA Guidelines, and the 2010 AHA Guidelines state that “Naloxone has no role in the management of cardiac arrest.” Note also that co-author Dr. Aaron Orkin was also a co-author of ‘Development and Implementation of an Opioid Overdose Prevention and Response Program in Toronto, Ontario’, Can J Public Health 2013;104(3):e200-e204. http://journal.cpha.ca/index.php/cjph/article/view/3788 Also, the above paper is from 2015, fours years after Toronto Public Health launched the POINT program, and could not have been part of any “extensive literature review” performed prior to Dr. McKeown’s approval of, or implementation of, the program.

6. Orkin AM, Bingham K, Klaiman M, Leece P, Buick JE, et al. (2015) An Agenda for Naloxone Distribution Research and Practice: Meeting Report of the Surviving Opioid Overdose with Naloxone (SOON) International Working Group. J Addict Res Ther 6:212. doi:10.4172/2155-6105.1000212

Page 5 Figure 1 quote BLS & Bystander Resuscitation Guidelines “No consensus on the role of ventilations” NONSENSE humankind has known for 5,000 years eat to much opium you stop breathing.

My response: Aaron Orkin and Pamela Leece  also co-authors Toronto Public Health’s article Development and implementation of an opioid overdose prevention and response program in Toronto, Ontario  Dr. Orkin also co-author 2015 AHA CPR guidelines.  Communication with Dr. Orkin

2nd Response:  The above paper is from 2015, fours years after Toronto Public Health launched the POINT program, and could not have been part of any “extensive literature review” performed prior to Dr. McKeown’s approval of, or implementation of, the program. The corresponding author, Dr. Aaron Orkin, and a co-author, Pamela Leece, are both co-authors of a publication on the POINT program in question: ‘Development and Implementation of an Opioid Overdose Prevention and Response Program in Toronto, Ontario’. This paper provides no scientific justification whatsoever for using Naloxone and chest compressions, and not rescue breathing, “whenever an unresponsive person is not breathing normally or showing obvious signs of life, even if the etiology is presumed to be opioid toxicity.”  Based merely on a very vaguely described “expert-facilitated discussion” had by “participants in the BLS and bystander resuscitation stream” the authors claim that “lay rescuers should presume that cardiac arrest has occurred” regardless of any evidence to the contrary. This is not science, and it is irresponsible and dangerous for you to rely on this paper as evidence in support of the POINT program. Table 2 (Program Resuscitation Training Protocols) indicates that the POINT protocol is the only protocol that does not include rescue breathing. Quotes: “The AHA recommendations state that “Naloxone has no role in the management of cardiac arrest.” “People at risk of dying from opioid overdose deserve high quality, evidence-based care.”

7. Seal KH, Thawley R, Gee L, Bamberger J, Kral AH, Ciccarone D, et al. Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: a pilot intervention study. Journal of Urban Health 2005 Jun;82(2):303-311.

Quote middle p. 305 “participants learned to preform rescue breathing”  p. 307 figure 2. Face Shield for rescue breathing.

My response: “Where are the cases of barrier masks Toronto Public Health received from the Ontario Harm Reduction Distribution Program?” http://www.ohrdp.ca/opioid-overdose-prevention/

Quote “With opioid overdoses, surviving or dying wholly depends on breathing and oxygen.” As with any breathing emergency it’s not a sudden witnessed cardiac arrest.

2nd response: This is a small pilot study (n = 20), undertaken in 2005 “to investigate the safety and feasibility of training injection drug using partners to perform cardiopulmonary resuscitation (CPR) and administer naloxone”, because “several recent feasibility studies have concluded that naloxone distribution programs for heroin injectors should be implemented to decrease heroin overdose deaths, but there have been no prospective trials of such programs in North America.”  This pilot study was not remotely designed to compare the value of chest compressions versus rescue breathing (it is not even a comparative study), nor to make conclusions about the safety and/or efficacy of chest compressions (with or without Naloxone), in cases of opioid overdose.  It in no way supports or even suggests the notion that rescue breathing should be abandoned in favour of chest compressions in cases of opioid overdose.

8. Travers AH, Rea TD, Bobrow BJ et al. Part 4: CPR overview 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, Circulation, 2010; 122(suppl 3):S676-S684.

My response: Article is dealing with sudden cardiac arrest not poisoning (drug OD) Part 12:7 2010 guidelines Reference 11 below.

2nd response: This section of the AHA’s Guidelines deals with sudden witnessed cardiac arrest, not opioid overdoses (acute respiratory failures).   

9. Travers AH, Perkins GD, Berg RA, Castren M, Considine J, Escalante R,Gazmuri RJ, Koster RW, Lim SH, Nation KJ, Olasveengen TM, Sakamoto T, Sayre MR, Sierra A, Smyth MA, Stanton D, Vaillancourt C; on behalf of the Basic Life Support Chapter Collaborators. Part 3: adult basic life support and automated external defibrillation: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation. 2015;132(suppl 1):S51–S83.

Quote: Treatment Recommendation
“No treatment recommendation can be made for adding naloxone to existing BLS practices for the BLS management of adults and children with suspected opioid-associated cardiac or respiratory arrest in the prehospital setting.”

Quote ‘existing BLS practices’ Rescue breathing then Naloxone continue rescue breathing until patient breaths adequately on their own.

My response: 2015 guidelines Public Health based their protocols on a future article??  See reference 11 the 2010 guidelines covers toxic ingestions.  So magically poisons, drugs changed their chemical structure and started causing death cardiac arrest?  Communication with Dr. Vaillancourt

2nd response:  This paper did not compare, or review literature on, the value of chest compressions versus rescue breathing, nor make conclusions about the safety and/or efficacy of chest compressions (with or without Naloxone), in cases of opioid overdose.  It in no way supports or even suggests the notion that rescue breathing should be abandoned in favour of chest compressions in cases of opioid overdose.   In fact, this paper noted the following: “Knowledge Gaps: Further research is needed to determine the optimal components of opioid overdose response education, the role of naloxone, and how these educational programs should be implemented and evaluated.” Further, this paper reviewed evidence on whether “opioid overdose response education, with or without naloxone distribution(I), compared with no overdose response education or overdose prevention education only…” affects outcomes.   It found only “very-low-quality evidence (downgraded for risk of bias, inconsistency, indirectness, and imprecision)…” pertaining to this research question, and made the following recommendation: “We suggest offering opioid overdose response education, with or without naloxone distribution, to persons at risk for opioid overdose in any setting (weak recommendation, very-low-quality evidence)”. This paper also states “We did not identify any published studies to determine if adding intranasal or intramuscular naloxone to conventional CPR is superior to conventional CPR alone for the management of adults and children with suspected opioid-associated cardiac or respiratory arrest in the prehospital setting.”

10. Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ 2013 Jan 30;346:f174.

Quote page 1 “Intervention OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone”

Quote page 2 “recognizing overdose by assessing for unresponsiveness and decreased respirations; and responding to an overdose by seeking help, providing rescue breathing, administering nasal naloxone, and staying with the person until medical personnel arrived or the person recovered”

2nd response:  The intervention studied in this paper was described with the following: “OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone.”  Chest compressions are not even mentioned.  This paper in no way supports or even suggests the notion that rescue breathing should be abandoned in favour of chest compressions in cases of opioid overdose.

11. Vanden Hoek TL, Morrison LJ, Shuster M, Donnino M, Sinz E, Lavonas EJ, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010 Nov 2;122(18 Suppl 3):S829-61.

Quote page 840-1 “Rescue breathing, then you may give Naloxone continue rescue breathing” “Naloxone has no role in the management of cardiac arrest”

My response: This above is correct as per all medicine past, present and future.  This article was reference 26 in Toronto Public Health’s article Note Dr. Morrison is mentioned bottom right corner ‘Development and Implementation of an Opioid Overdose Prevention and Response Program in Toronto, Ontario’, Can J Public Health 2013;104(3):e200-e204. http://journal.cpha.ca/index.php/cjph/article/view/3788

E-mail from Morrison LJ Oct 8, 2012

From Laurie Morrison   MorrisonL@smh.ca
To James Thompson
CC ‘Aaron Orkin (aorkin@gmail.com)’
Oct 8, 2012

Hi James
Yes I helped craft them in accordance with the guidelines and feel the approach to chest compression only is the right way to go for many reasons. Happy to discuss with you at any time.  Aaron Orkin (copied here) and Toronto public Health were more involved than I was as I was just the expert brought in to help out.
Cell is 4165245434 or we could set up a face to face by email if you prefer.
Laurie

From: James Thompson [mailto:jgary.thompson@mail.utoronto.ca] Sent: Wednesday, October 03, 2012 5:02 PM To: Laurie Morrison Subject: naloxone training
Dr. Morrison:
I have just found out that RESCU was part of Toronto Public Health’s naloxone protocols.  I think they should be changed, as there is no scientific evidence for chest compressions only in opiate overdose.
See Attached   ILCOR  and Amer Heart Assoc. Guidelines 2010

Please reply ASAP
Remember the Magic
Gary Thompson

Dr. Morrison was not happy to discuss when told brining a tape recorder. She phoned the police. Get a phone call “Gary can you come to the station” “Sure be right there” Police constable “Gary I want to shake your hand you have been saving lives, bad news is Dr. Morrison wants no contact.” “Fine by me she is a nut”

Dr. Laurie Morrison Co-Chair AHA & ILCOR Guidelines on toxic ingestions
2010 AHA Guidelines Part 12.7:
http://circ.ahajournals.org/content/122/18_suppl_3/S829.full#sec-80

ILCOR 2010 Part 8.5 Drug Overdose and Poisoning http://www.resuscitationjournal.com/article/S0300-9572(10)00453-3/fulltext#sec2260

UNDOC/WHO 2013 Opioid overdose Page 7 layman’s language
https://www.unodc.org/docs/treatment/overdose.pdf

Compressions only CPR AHA Guidelines 2010 Part 4
http://circ.ahajournals.org/content/122/18_suppl_3/S676.full.pdf+html

2nd response:  In Part 12.7, the section of this paper that deals with “Cardiac Arrest Associated With Toxic Ingestions”, it states:

  • As with any patient in cardiac arrest, management of the patient with a toxic exposure begins with support of airway, breathing, and circulation…”
  • “Opioid Toxicity: There are no data to support the use of specific antidotes in the setting of cardiac arrest due to opioid overdose…”
  • “Naloxone has no role in the management of cardiac arrest.”
  • “In the patient with known or suspected opioid overdose with respiratory depression who is not in cardiac arrest, ventilation should be assisted by a bag mask, followed by administration of naloxone and placement of an advanced airway if there is no response to naloxone.”

Further, this paper acknowledges the obvious “ethical challenges related to withholding established care from patients who are unable to provide informed consent…” and that “poisoned patients may deteriorate rapidly.” Note also that Laurie Morrison was also a co-author of ‘Development and Implementation of an Opioid Overdose Prevention and Response Program in Toronto, Ontario’, Can J Public Health 2013;104(3):e200-e204. http://journal.cpha.ca/index.php/cjph/article/view/3788  My understanding thus far is that:

  • You have no science whatsoever to support your abandonment of the standard of care – live-giving rescue breathing in response to an opioid overdose (a respiratory emergency).
  • You prefer that precious, critical moments during such a life-threatening emergency be spent giving potentially harmful chest compressions rather than providing the needed oxygen, even though cardiac arrest occurs with far less frequency than respiratory emergency and is secondary to respiratory emergency during an opioid overdose, Naloxone takes time to become effective, Naloxone does not always work, and chest compressions at best move around small, insufficient amounts of oxygen in a body that is already hypoxic.

END OF DR. McKeown’s References 

2010 AHA & ILCOR Guidelines found here  Response to Emily Oliver Clinicians see opioid overdose daily in a clinical situation.  Terminally ill are kept ‘comfortable’ to wit OD narcotics cause of death acute respiratory failure.

All 70+ references from 2015 AHA & ILCOR CPR guidelines on opioid overdose and comments  ALL SAY RESCUE BREATHING NO MENTION ANYWHERE CHEST COMPRESSIONS ONLY
https://aliascpr.wordpress.com/2015/12/13/2015-ilcor-and-aha-references-opioid-od/

 

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@GaryCPR

EMN 2015; 37(12):31 http://journals.lww.com/em-news/Fulltext/2015/12000/Letter__Flaws_in_Toronto_s_Opioid_Overdose.14.aspx Article in the 2015 AHA & ILCOR guidelines 'Opioid OD' https://youtu.be/PX0HQuaNS_I

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