Carfentanil (which had previously been seen in neighboring states) has now been officially identified in Connecticut. The discovery of this drug 100 times stronger than Fentanyl poses questions: How much danger does Carfentanil (or Fentanyl for that matter) pose to EMS? How can we in EMS protect ourselves from exposure to these drugs? What should an EMS responder do if they believe they are exposed or one of their coworkers has been exposed?
Every EMS responder should ask these questions and seek answers from both their medical control and from their services. Unfortunately, I have had a hard time finding a one-stop source of good information on this question. What follows is my attempt to share what I believe based on what I have read and people I have talked to. It should not replace the information you get from your service.
Can Fentanyl or Carfentanil kill you? Yes, they can. If you inhale a certain amount of powder, you can go into respiratory arrest. If no one gives you Naloxone or breathes for you with a bag valve mask, you may become the first EMS responder to die on the job as a result of accidental opioid exposure.
Recently a police officer in Ohio fell ill after brushing white powder off his shirt, The powder went airborne and he inhaled it. It is unclear from news reports what exactly happened next. The article below says the man passed out an hour later and had to receive four doses of Naloxone
This article suggests he collapsed within minutes of the exposure, which makes more sense.
Neither article are clear about whether or not the officer suffered respiratory depression. I asumme that he did.
If you directly inhale powdered Fentanyl, particularly if you are opioid naive, you will likely overdose, depending on the amount you inhale. It doesn’t take a lot. A 0.1 gram single bag of east coast powdered heroin that may in fact not be heroin at all, but Fentanyl cut with sugar or caffeine, or Carfentanil cut with substances, could be enough to kill you. I have had experienced users tell me that last year a batch called Black Jack was strong enough that two users could get high off one five dollar bag. If you find yourself in a situation where there is powder on your patient or in close proximity to you to the point that it has a chance of getting in your nose, you should have PPE on. PPE should include nitrile gloves, eye protection, a N-95 respirator and it would be beneficial if you have long sleeves.
What are the chances of getting powder up your nose? Not great. In 25 years of dealing with heroin overdoses, I’ve never gotten any powder up my nose. But if only a few grains of Carfentanil can overdose you, that is not a chance I want to play with. Better safe than sorry.
If you walk into a room that looks like a drug factory and everyone else is wearing gas masks and the air is thick with fumes, turn around and walk out. If it is an ordinary overdose scene, use due caution. Understand the difference between a hazmat situation and an isolated overdose scene where a substance user has overdosed from injection or snorting.
Carfentanil and Fentanyl can be absorbed through the skin, but that does not mean that simple contact with unbroken skin will instantly knock out a responder. It won’t. If you get the powder on your skin, wash it off. While dry Fentanyl powder can be absorbed through unbroken skin, it takes hours to days, and requires fairly large amounts to affect you. The more powder and the longer it is on the skin, the larger the risk. Wash the powder off with water, not hand sanitizers, which may contain alcohol which can speed absorption.
The DEA recently released Fentanyl: A Briefing Guide for First Responders that should be required reading. That said, it seems to be written almost entirely for police and not so much for EMS and medical personnel.
Take this passage:
Personnel should look for any cyanosis (turning blue or bluish color) of victims, including the skin or lips, as this could be a sign of fentanyl overdose caused by respiratory arrest. Further, before proceeding, personnel should examine the scene for any loose powders (no matter how small), as well as nasal spray bottles, as these could be signs of fentanyl use. Opened mail and shipping materials located at the scene of an overdose with a return address from China could also indicate the presence of fentanyl, as China‐based organizations may utilize conventional and/or commercial means to ship fentanyl and fentanyl‐related substances to the United States.
“Further, before proceeding”
If a patient is unresponsive and cyanotic, breathing 2 times a minute, unless they have fallen into a Scarface mountain of powder or any amount of powder that I think might compromise my ability to perform my duty of saving their life, I am going to put my gloves on, don my N-95 mask), grab my bag-valve-mask and start breathing for them. I am most certainly not going to wait to treat the patient until after I have scoured the cluttered room for hidden packages from China.
Scene safety yes, but unless you are in a hazmat scene, letting a person die while you are looking for possible powder that undisturbed will not harm anyone, is misguided. If on the other hand, everyone on the scene is either unmoving on the floor and the powder is so thick on the ground you can leave footprints in it, then I am going to turn around and exit.
But what if you are exposed? What if when you turn your patient with agonal respirations over, you find powder on your exposed wrist or you simply start to feel dizzy on an overdose call. What do you do if you feel you have been exposed and are starting to show symptoms. Do you self-administer Naloxone or have your partner hit you with a dose of Naloxone?
Our medical guidelines call for Naloxone only to be used for patients who are in respiratory depression. Do those same guidelines apply to exposed first responders? According to the DEA booklet:
Overdose symptoms can include drowsiness, disorientation, sedation, pinpoint pupils, skin rash, clammy skin, and respiratory depression or arrest. The onset of these symptoms usually occurs within minutes.
If an exposure occurs, seek immediate medical attention as fentanyl and other fentanyl‐related substances can be very fast‐acting. In cases of suspected exposure, contact emergency medical services (EMS), or, if feasible, have EMS on scene prior to conducting enforcement activity. If an exposure occurs, remove the exposed individual from the contaminated environment (preferably to a location with fresh air). If they exhibit overdose symptoms, immediately administer naloxone by personnel trained in its use. Naloxone is an antidote for opioid overdose. Immediately administering naloxone can reverse an opioid overdose.
Depending on the drug’s purity and potency multiple doses of naloxone may be required to stabilize the victim. 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.
That’s a lot of Naloxone. The way the passage is written, the person is getting at least 5 doses even though they are already breathing. And do we need to be giving Naloxone to everyone who feels dizzy or clammy? What does your medical control say? Maybe it is just a poorly written passage. And why no mention of using a bag valve mask? If you are carrying Naloxone, you should also be carrying a bag valve mask.
From media reports, it looks like some responders are being given Naloxone based on onset of symptom.
This report describes the responder who was dizzy and had a high blood pressure and rapid pulse (opioids make your pressure and pulse rate go down not up) getting Naloxone right into the nose and the administrator not having time to attach the atomizer.
“I instantly felt very dizzy and I also felt like I was going to pass out, and I didn’t want to pass out in the basement,” Phillips said.
He got himself up to the kitchen and into a kitchen chair. The EMS workers hooked him up to monitor, which showed an elevated pulse and a blood pressure that was “ridiculously high.”
Phillips took out a shot of Narcan, which Harford deputies and municipal police officers carry with them to revive overdose victims.
An EMS worker took the shot from him and administered it via his nose. Phillips said there was no time to put the “atomizer,” which converts the Narcan from a fluid to a mist, on the end of the hypodermic, so the fluid was shot right into his nose.
He said the fluid gave him a “burning sensation,” but “I didn’t care, I just wanted the Narcan in me.”
Maybe this is just an example of the press getting the story wrong. But as reported, this person did not need Naloxone under standard EMS treatment guidelines. And everyone, please be sure to take the time to attach the atomizer, otherwise the Naloxone will have difficulty crossing the blood brain barrier. In other words, it won’t work, other than as a placebo if administered to a conscious patient concerned about overdosing. As I mentioned, such a use would currently be against our medical control guidelines.
Here is another example of Naloxone being given for exposure.
Read the new DEA guidelines for an understanding of the dangers Carfentanil and Fentanyl pose, but also hope for the development and distribution of guidelines by EMS medical directors for EMS personnel. If a nationwide group of EMS physicians or even your medical control physician says administer Naloxone on first sign of exposure or first hint of symptom, then I will give that idea more credibility. I don’t expect they will.
As serious a threat as Carfentanil and Fentanyl pose to EMS, we need accurate news coverage of reported first responder exposure and and symptoms they develop, and we need medically reviewed and evidenced based guidelines on how we should respond. Otherwise, we may have hysteria.
In summary, think about things before they happen to you.
What gear am I going to have on my when I go into a call for an overdose?
I am wearing nitrile gloves, eye protection, and I have a N-95 mask in my pocket ready for quick deployment. Wearing your basic PPE should protect you.
What am I going to do if I get powder on my skin?
I’m going to wash it off for at least fifteen minutes.
What am I going to do if a first responder says to me, “I feel dizzy, hit me with some narcan, I think I’m going to die.”
I’m going to follow my current guidelines. I will monitor the patient and if he shows signs of respiratory depression, I will administer Naloxone per protocol. If I have any doubt about administering Naloxone, I will call medical control.
How much Naloxone am I going to carry in my ambulance?
As much as my company will allow me to carry. I have four milligrams in my in-house bag, and usually another four milligrams on the ambulance shelf. I have never had to give more than 4 milligrams ( and is a rare exception) to reverse an opioid overdose (waiting 5 minutes between doses while bagging the patient). Five minutes can seem like an eternity, but if you are effectively bagging a victim of opioid overdose, you just need to be patient. That said, Carfentanil has been reported to require stronger doses of Naloxone, so we all may need to start carrying more Naloxone.
Stay safe, friends.