CASE REPORT depression, respiratory, naloxone; naloxone, intralingual

Intralingual Naloxone Injection for Narcotic.Induced Respiratory Depression

Narcotic-induced respiratory depression in a 25-year-old man was com- pletely reversed with the administration of intralingual naloxone. Use of this route has been advocated when the IV route is unobtainable. No specif- ic case report or case data have been published regarding this route. [Maio RE Gaukel B, Freeman B: Intralingual naloxone injection for narcotic-in- duced respiratory depression. Ann Emerg Med May 1987;16:572-573.]

I N T R O D U C T I O N W naloxone is a well-established therapy to reverse narcotic-induced respi-

ratory depression. At times, expecially in the prehospital setting, this may be difficult. Subcutaneous and intramuscular naloxone can be used, but these routes give erratic uptake. 1-3 Endotracheal naloxone has been advocated, 4-7 yet this may also be difficult to accomplish in the prehospital setting.

Some authors have advocated intralingual injection of drugs, stating that high vascularity makes it a combination between intramuscular and IV in- jection, s-14 Rappolt has advocated the use of intralingual injections for nar- cotic overdose. 14 However, he gives no specific case data for this method alone being used to reverse narcotic-induced respiratory depression. A recent study in dogs showed that intralingnal naloxone can rapidly reverse narcotic- induced respiratory depression, is

We present the case of a patient in whom intralingual naloxone was the only method used to reverse narcotic-induced respiratory depression. To our knowledge, this is the first such reported case.

CASE REPORT Paramedics found a 25-year-old man unresponsive to deep pain on a

bathroom floor. Bystanders stated that the individual "did some heroin." Vi- tal signs were as follows: blood pressure, 140/60 m m Hg; pulse, 80; and respi- rations, 10 and very shallow. The pupils were constricted. Several track marks were noted on the arms, and a needle and syringe were seen in the bathroom. The airway was secured with an oropharyngeal airway, and respi- ration was assisted with high-flow oxygen using a Robert Shaw ventilator (Robert Shaw Resuscitator Co, Irvine, California).

Attempts at IV access were unsuccessful. Radio contact with the appropri- ate hospital was obtained. The paramedics were ordered to give one ampule of naloxone (0.4 mg) into the mid-ventral surface of the tongue and intubate the patient. The injection was given with a 22-gauge needle. Aspiration was made prior to injection, and no blood was returned. Approximately 30 sec- onds after the injection was given, and before an intubation attempt was done, the patient's rate of respiration increased to 20, and he became more responsive to pain.

On arrival at the hospital, approximately ten minutes after intralingual injection, the patient was awake and talking spontaneously with slightly slurred speech, but was not oriented to place and time. His blood pressure was 112/70 m m Hg, pulse was 78, and respirations were 16 with full, bilateral breath sounds. The pupils were equal and reactive. The cardiac moni tor showed a sinus rhythm. Tracks were noted on the arms bilaterally.

Ear, nose, and throat examination revealed a small puncture wound on the ventral surface of the junction of the proximal and mid thirds of the tongue, just to the right of midline. There was no hematoma, swelling, or active

Ronald F Maio, DO* Barry Gaukel, AEMT1- Bruce Freeman, EMT~ Lansing, Michigan

From the Department of Emergency Medicine, St Lawrence Hospital;* the Department of Medicine, Section of Emergency Medicine, Michigan State University;t and the Lansing Fire Department, Lansing, Michigan.::

Received for publication July 7, 1986. Accepted for publication December 1, 1986.

Address for reprints: Ronatd F Maio, DO, Department of Emergency Medicine, St Lawrence Hospital, 1210 W Saginaw, Lansing, Michigan 48915.

16:5 May 1987 Annals of Emergency Medicine 572/99

INTRALINGUAL NALOXONE INJECTION Maio, Gaukel & Freeman

bleeding. T h e leve l of consc iousnes s con t inued to increase. Several unsuc- cessful a t t empt s at per ipheral IV l ine p l a c e m e n t were made.

Wi th in f ive m i n u t e s of a d m i s s i o n the pa t ient was alert and comple t e ly oriented. He refused fur ther a t t empt s at IV p l a c e m e n t e i ther per ipheral ly or centrally. He did accept i n t r amuscu la r i n j e c t i o n of 0 .4 m g n a l o x o n e . H e voiced no compla in t s of any pain in his mouth .

The pa t ient admi t t ed that the sub- s tance he in jec ted was heroin. The re was no h i s to ry of o the r r ecen t drug use. He refused s e r u m and ur ine drug sc reen . A p p r o x i m a t e l y t h r e e h o u r s after a d m i s s i o n the pa t i en t was dis- charged. T h e v i t a l s igns were as fol- lows: blood pressure, 110/68 m m Hg; p u l s e , 82; r e s p i r a t i o n s , 18; t e m - perature, 37.1 C. He voiced no com- p la in t s . H e had r e c e i v e d a t o t a l of three ampules (0.4 mg/ampule ) of in- t r a m u s c u l a r n a l o x o n e . T h e p a t i e n t wen t h o m e accompan ied by a fr iend and was referred for drug abuse coun- seling. A t t e m p t s at long- te rm follow- up were unsuccessful .

D I S C U S S I O N IV na loxone has an onse t of ac t ion

of one to two minu tes . 16 In this case t h e p a r a m e d i c n o t i c e d c l i n i c a l changes w i t h i n 30 seconds. Perhaps this effort was due to noxious s t imul i of the in j ec t ion itself. In t he con t ro l group of t he can ine s tudy on intra-

l ingual naloxone, 11 an increase in ven- t i l a t ion was no t ed one m i n u t e after i n j e c t i o n of sa l ine . T h i s was p o s t u - lated to be secondary to the noxious s t imul i of the in t ra l ingual inject ion.

A n o t h e r e x p l a n a t i o n m a y be t h a t the drug is ge t t ing in to the cerebral c i rcu la t ion faster than w i t h peripheral IV i n j e c t i o n . T h e c a n i n e s t u d y 15 showed a s ignif icant increase in ven- t i lat ion, wel l above basel ine and con- trol, w i t h i n one m i n u t e af ter intra- l ingual na loxone was given.

SUMMARY We report a case of reversal of nar-

co t i c - induced resp i ra tory depress ion solely by in t ra l ingual inject ion. There w e r e no s h o r t - t e r m c o m p l i c a t i o n s , and the pa t ien t was lost to long- te rm fol low-up. To our k n o w l e d g e this is the first repor ted case of the use of in- t ra l ingua l n a l o x o n e a lone to reverse n a r c o t i c - i n d u c e d r e s p i r a t o r y depres- sion.

REFERENCES 1. Greenblatt DJ, Koch-Weser J: Intramuscular injection of drugs. N EngI J Med 1976;295: 542- 546.

2. Alper PR: Legitimate indications for intra- muscular injections. Arch Intern Med I978; 138:1705-1710.

3. McGuigan MA, Mitchell AA: Prolonged ac- tion of intramuscular naloxone {letter). Br Med J 1977;2:580.

4. Redding J8, Asuncion J8, Pierson JW: Effec- tive routes of drug administration during car-

diac care. Anesth Anal 1967;46:253-258.

5. Standards for cardiopulmonary resuscitation and emergency cardiac care. JAMA 1974;227: 838-868.

6. Elam JO: The intrapulmonary route for car- diopulmonary resuscitation drugs, in 5afar P (ed): Advances in Cardiopulmonary Resuscita- tion. New York, Springer-Verlag, 1977, p 132.

7. Greenberg MI, Roberts JR, Baskins SI: Endo- tracheal naloxone reversal of morphine-induced respiratory depression in rabbits. Ann Emerg Med 1980;9:289-292.

8. Hapke HJ: Die intralinguale injektion. Berliner und Munchener Tierartliche Wochen~ schr 1963;76:I5-I7.

9. Sklar E, Schwartz M: An emergency site of injection. Oral Surg I965;19:28-31.

10. Nichols WA, Cutright DE: Intralingual in- jection site for stimulant drugs. Oral Surg I971;32:677-684.

I1. Quent JT, McGovern JP: When every second counts, in Cohen IJ (ed): Touching All Basics. New York, EM Books, 1974, p 3.

12. Moeschlin S: Intraglossale notfallinjection. Deutsche Medizinische Wochenschr 1972;97: 741.

13. Bullough J: Intraglossal injections in uncon- scious patients, an alternative to intravenous injection. Lancet 1958;1:80-81.

I4. Rappoh RT: Narcotic antagonists admin- istered sublingually in heroin overdoses. Clin Toxicoi 1974;7:343-345.

15. Maio RF, Griener JE, Clark MR, et ah Intra- lingual naloxone reversal of morphine-induced respiratory depression in dogs. Ann Emerg Med 1984;12:1087-1091.

16. Jaffe JH, Martin WR: Narcotic analgesics and antagonists, in Goodman LS, Gilman A (eds): The Pharmacological Basis of Therapeut- ics, ed 5. New York, MacMillan Publishing Co, 1975, p 273-275.

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