What is the management for a patient with respiratory arrest, such as benzodiazepine (benzo) overdose, in a subacute hospital without anesthesia or Intensive Care Unit (ICU) support, given Basic Life Support (BLS) training but no advanced airway training?

From the Guidelines

In a respiratory arrest scenario like a benzodiazepine overdose at a subacute facility without anesthetics or ICU support, your initial management should focus on basic life support measures while awaiting emergency transfer, prioritizing bag-valve-mask ventilation with high-flow oxygen as the primary intervention. Begin by positioning the patient, opening the airway using head-tilt chin-lift or jaw thrust, and immediately providing bag-valve-mask ventilation with high-flow oxygen, as recommended by the 2023 American Heart Association guidelines 1. Ensure a good seal with the mask using a two-handed technique if possible, with a second rescuer squeezing the bag at 10-12 breaths per minute.

For benzodiazepine overdose specifically, consider the potential for co-ingestion of other substances, such as opioids, and administer naloxone 0.4-2mg IV/IM/IN if opioid co-ingestion is suspected, as suggested by the guidelines 1. If available and you're trained, an LMA (laryngeal mask airway) can be inserted if bag-valve-mask ventilation is ineffective due to airway obstruction or inability to maintain a seal. However, only attempt LMA insertion if you have received proper training, as emphasized in the guidelines 1.

Key considerations in management include:

• Maintaining oxygenation through effective bag-valve-mask ventilation as the priority until advanced help arrives
• Monitoring vital signs including oxygen saturation, heart rate, and blood pressure
• Documenting all interventions
• Calling for emergency transfer immediately, as these patients require definitive airway management and potentially flumazenil (benzodiazepine antagonist) administration in a higher-level care setting, as highlighted in the guidelines 1.

From the FDA Drug Label

The patient who has satisfactorily responded to naloxone should be kept under continued surveillance and repeated doses of naloxone should be administered, as necessary, since the duration of action of some opioids may exceed that of naloxone Naloxone is not effective against respiratory depression due to non-opioid drugs and in the management of acute toxicity caused by levopropoxyphene.

In the event of a code blue for respiratory arrest due to a benzo overdose, the management would not involve naloxone administration as it is not effective against respiratory depression due to non-opioid drugs like benzodiazepines.

• The most appropriate course of action would be to provide bag-valve-mask (BVM) ventilation until the ambulance arrives.
• If airway occlusion occurs, it is not recommended to use an LMA (Laryngeal Mask Airway) without proper airway training.
• It is essential to follow BLS (Basic Life Support) guidelines and provide continuous CPR (Cardiopulmonary Resuscitation) if the patient is unresponsive and not breathing.
• The patient should be transported to a hospital with ICU (Intensive Care Unit) support as soon as possible for further management 2 2.

From the Research

Management of Respiratory Arrest

In a subacute hospital without anaesthetics or ICU support, management of a code blue for respiratory arrest, such as a benzo overdose, would involve:

• Calling for emergency medical services (EMS) immediately
• Initiating basic life support (BLS) measures, including chest compressions and ventilation
• Using a bag-valve-mask (BVM) device to provide ventilation, as it is a readily available and effective method for providing oxygenation and ventilation in this setting 3, 4

Airway Management

Given that you are BPT trained but not airway trained, the use of a laryngeal mask airway (LMA) may not be recommended as it requires specific training and expertise. However, in the event of airway occlusion, an LMA could be considered as an alternative to BVM ventilation, but only if you have received proper training and are comfortable with its use 3.

• BVM ventilation would be the primary method of ventilation, with the goal of providing adequate oxygenation and ventilation until EMS arrives
• If airway occlusion occurs, consideration could be given to using an LMA, but this would depend on your individual training and comfort level with the device

Ventilation Strategies

Studies have shown that BVM ventilation can be an effective method for providing ventilation during cardiac arrest, especially when used with continuous chest compressions 4.

• The use of BVM ventilation with continuous chest compressions has been shown to be a reliable and effective strategy during CPR under simulation conditions
• LMA ventilation has also been shown to provide higher minute ventilation volumes and rates compared to BVM ventilation, but may require more training and expertise to use effectively 3, 4