# woman down



## Angel (Aug 1, 2014)

I'm bored so here's a scenario

It's the middle of a sunny afternoon and you are dispatched to a bus stop for an unresponsive female. as you and the engine pull up, you see bus security wave you in and hes pointing to the patient.

that's all you get for now.


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## NomadicMedic (Aug 1, 2014)

Initial assessment. Vitals. BG. 12 lead.


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## Angel (Aug 1, 2014)

as you walk up to the patient she is slumped to the side, she does not wake up or make any eye contact as you call out "Ma'am" you notice some "belly breathing" but it appears shallow.

vitals: P 106 weak, regular, R ~4 and shallow, BP 118/74, BGL 132
4 lead: S-Tach 12 lead: same

your nearest hospital is approx 18 mins away, with no traffic


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## NomadicMedic (Aug 1, 2014)

Pupils? Skin signs? Pulse ox. 

NPA and BVM while you get out the Narcan.


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## DrParasite (Aug 1, 2014)

how old is she?  any odor of alcohol?  anything in her pockets (needles, medications, etc)? how are her pupils?  any signs of trauma?  any witnesses see what happened prior to this incident?

initial differential diagnosis would be an overdose.

initial intervention would be a BVM to increase her respirations.  see if some narcan helps her respirations.  if not, consider tubing her and taking her to the hospital.


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## Angel (Aug 1, 2014)

sorry forgot about her age, you estimate her age to be 30 years old

skin sx: warm and dry
pupils: 2, both inside (ambulance) and outside 
SpO2: 89%

no odor of ETOH but as you're loading her into the back of the ambulance, someone hands you a purse. Captain comes up and states per security she was there ~15 mins and he thought she was sleeping but wasn't able to wake her up so called 911

you initiate NPA and BVM, SpO2 increases to 100%

now heres the question, what route are you going to give the narcan? IV or IN?


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## chaz90 (Aug 1, 2014)

IN Narcan, dose of ~1 mg. Patiently continue using BVM while hooked up to EtCO2 and monitor for increase in spontaneous resps. If the initial IN dose doesn't start to increase resps after ~10 minutes, consider use of titrated IV Narcan and be looking towards intubation if that doesn't work.


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## Angel (Aug 1, 2014)

1mg IN narcan does not work and after 2 attempts you can not get an IV

your partner continues bagging without difficulty


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## chaz90 (Aug 1, 2014)

Hmm. IN Narcan doesn't work to even slightly increase respiratory effort? Evidently this is a route based scenario. Well, not to get too bogged down on one pathway, but this lady still screams OD. Give some IM Narcan, have someone else try for an IV in unconventional sites, look for an EJ, or go for an IO if you must. If the Narcan through any and all routes continues to fail, we're going to have to have some kind of IV/IO access for intubation anyway.


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## STXmedic (Aug 1, 2014)

I'm with Chaz, IM narcan and get a line. She screams OD.

What's in her purse? Any pill bottles in it, or anything to hint towards medical conditions. Any track marks on her?

Further vitals- temp? EtCO2 (I'm sure it's high, but I'd have her on one anyway), is she responsive to pain? If so, to what extent? ie localizing, withdraw, etc. Does she arouse with pain and able to follow commands? Any obvious signs of facial droop?


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## DesertMedic66 (Aug 2, 2014)

chaz90 said:


> Hmm. IN Narcan doesn't work to even slightly increase respiratory effort? Evidently this is a route based scenario. Well, not to get too bogged down on one pathway, but this lady still screams OD. Give some IM Narcan, have someone else try for an IV in unconventional sites, look for an EJ, or go for an IO if you must. If the Narcan through any and all routes continues to fail, we're going to have to have some kind of IV/IO access for intubation anyway.



Same treatment that I would do. Continue to bag the patient with an NPA in place. If IN Narcan had no effect I would go to IM as I have another provider look for other IV sites (foot, ankle, EJ). If I still have no line established and the IM Narcan gives no response then I am going to drill the patient. Either proximal tibia or humoral. For my area I would have to contact base in order to titrate Narcan to respiratory dive but still keep the patient under, so I would have someone on the phone talking to the doc. 

I don't know if anyone has asked but what was in the purse? Does the patient have any track marks? Why can't the IV be established (lack of veins or scar tissue)?

I would also consider securing an airway on the patient better than an NPA.


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## Angel (Aug 2, 2014)

STXmedic said:


> I'm with Chaz, IM narcan and get a line. She screams OD.
> 
> What's in her purse? Any pill bottles in it, or anything to hint towards medical conditions. Any track marks on her?
> 
> Further vitals- temp? EtCO2 (I'm sure it's high, but I'd have her on one anyway), is she responsive to pain? If so, to what extent? ie localizing, withdraw, etc. Does she arouse with pain and able to follow commands? Any obvious signs of facial droop?



you check her bag and find two big pill bottles with the labels ripped off. 
one has a "V~" on it. extra points if you know what it is without looking it up. and the other one you are not sure. no track marks, veins are not prominent and difficult to palp, my go to is 18G, maybe something smaller?

So, I think were about done with this scenario?


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## DesertMedic66 (Aug 2, 2014)

Angel said:


> you check her bag and find two big pill bottles with the labels ripped off.
> one has a "V~" on it. extra points if you know what it is without looking it up. and the other one you are not sure.
> 
> So, I think were about done with this scenario?



It's defiantly Viagra. It's the only one that makes sense..


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## STXmedic (Aug 2, 2014)

I think we were done when Chaz gave narcan...


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## LACoGurneyjockey (Aug 2, 2014)

Lupus. And Somas are her ideal treatment for it.


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## Akulahawk (Aug 2, 2014)

The fact that she's got pinpoint pupils says she's possibly an opiate OD. However, could she have taken a benzo and an opiate? If she accidentally ODs on both... the narcan won't touch a benzo's effects.


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## STXmedic (Aug 2, 2014)

Doesn't really change the treatment, though. Narcan doesn't work, then airway maintenance/breathing support and transport. I don't think anybody is going to be giving flumazenil in the field (or likely in the ED...)


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## Angel (Aug 2, 2014)

DesertEMT66 said:


> It's defiantly Viagra. It's the only one that makes sense..



lol howd you know

ok were done and heres my take:


in this case route wasnt the biggest issue, it was dose. here our standard dose for adults is 2mg increments up to 6mg. with 2 mg IN she had a 1 point increase in GCS, 4mg IN and ~7 mins she began to open her eyes, start breathing on her own with NRB and started mumbling. by the time we got to the ER she was awake and able to answer some questions. we identified the bottles as vicodin (like viagra but different) and soma never did figure out how much she took though. 

i like that some of you were aggressive with the airway and wanted to intubate right away, because i didnt even consider it until later (silly intern) . but she was getting more responsive.  

also the only reason i wouldnt have IOd her even after missing the IV attempts is because an IV isnt critical for ODs, (since we can give it so many other routes) if she wouldve deteriorated or arrested then yes, but otherwise they are a last resort for unstable patients.


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## STXmedic (Aug 2, 2014)

Angel said:


> also the only reason i wouldnt have IOd her even after missing the IV attempts is because an IV isnt critical for ODs, (since we can give it so many other routes) if she wouldve deteriorated or arrested then yes, but otherwise they are a last resort for unstable patients.



Narcan can be given IN, yes. Anecdotally (from my personal experience, and from others here having similar experience) IN is very variable and unreliable, though. I don't even consider IN anymore except for certain situations because its been so unpredictable for me. As for IO, I'd probably only still if I needed to give meds for intubation. If it's just for narcan, I'm fine with IM.


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## Angel (Aug 2, 2014)

ive never given it IM before, roughly how long does it take for you to see changes?
is your dosing different for IV/IN vs IM? i know here if its IM we are supposed to give .2mg/kg max of 6 but it comes in 2mg/2ml so we just stick with that


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## STXmedic (Aug 2, 2014)

1-2 minutes typically. It's certainly not as quick as IV, but they also seem to come around slower (read: less vomiting).

Our dosing doesn't change  with the route. Up to 2mg, repeated once, then calling for more. We don't typically titrate them to respirations, though. We "treat and street" a lot, though. Well, for heroin ODs that is...


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## Akulahawk (Aug 2, 2014)

IIRC the protocols for naloxone that I was familiar with were basically 2mg, mr x1. The routes back then were either IV or IM and if we were to give it IV, we were to give it very slowly. I've almost always given naloxone by IV. I've given it once by IM. I believe an option we had/have was to divide the dose and give 1/2 by IM and the other 1/2 by very slow IV. It seemed to take a couple minutes for the patient to come around when I gave it IM. Apparently the absorption rate is quite a bit slower so the patients wake up less upset and have less vomiting. I suppose that in a way, it's a lot "nicer" to do than to give it IV. 

Incidentally, I actually forgot about Vicodin as one of those "V" medications. I guess I could have asked what the pills in the bottles looked like...


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## Angel (Aug 2, 2014)

i tried to describe how the vicodin looked using the keyboard but it probably wasnt very helpful. the only reason i knew it was vicodin off the bat was because ive seen the tabs like that before. the soma we were stumped till we got to the ER. even still, her symptoms with the labels etched off just seemed fishy.


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## AcadianExplorer1910 (Aug 23, 2015)

Angel said:


> I'm bored so here's a scenario
> 
> It's the middle of a sunny afternoon and you are dispatched to a bus stop for an unresponsive female. as you and the engine pull up, you see bus security wave you in and hes pointing to the patient.
> 
> that's all you get for now.


scene safety, assess Pt., Vitals, hook up Pt. to monitor as well, 12 lead, ask Pt. SAMPLE; OPQRST,  determine whether to transport unless patient refuses transport.


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## medichopeful (Aug 24, 2015)

AcadianExplorer1910 said:


> scene safety, assess Pt., Vitals, hook up Pt. to monitor as well, 12 lead, ask Pt. SAMPLE; OPQRST,  determine whether to transport unless patient refuses transport.



Fairly certain an unresponsive patient won't be answering too many questions 

Try thinking outside of the box a little bit, you'll be a much better provider!


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## redundantbassist (Aug 24, 2015)

medichopeful said:


> Fairly certain an unresponsive patient won't be answering too many questions
> 
> Try thinking outside of the box a little bit, you'll be a much better provider!


"MFR"


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## medichopeful (Aug 24, 2015)

redundantbassist said:


> "MFR"



The title someone has shouldn't limit how they think if they want to progress!


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## exodus (Aug 24, 2015)

redundantbassist said:


> "MFR"


MFR is equal to EMT over there.


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## AcadianExplorer1910 (Aug 24, 2015)

oh yeah sorry i forgot bout the unresponsiveness. doing the SAMPLE, OPQRST is a instinct yikes sorry


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## Tigger (Aug 24, 2015)

We don't use IN Naloxone because (and I hate this) "we are too good for IN, so we aren't buying it." Sometimes egos get in the way. So she would have gotten 0.4mg IM. If that wasn't effective, she would have been intubated and that would have been that. Our previous medical director hated Naloxone for whatever reason, and any question of polypharm OD was to be intubated. So right or wrong, that's what would have happened here.


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## EMT11KDL (Aug 25, 2015)

Tigger said:


> We don't use IN Naloxone because (and I hate this) "we are too good for IN, so we aren't buying it." Sometimes egos get in the way. So she would have gotten 0.4mg IM. If that wasn't effective, she would have been intubated and that would have been that. Our previous medical director hated Naloxone for whatever reason, and any question of polypharm OD was to be intubated. So right or wrong, that's what would have happened here.



that is how my old agency was, you dont come around with the first dose of narcan usually .8 with a splash, your gag reflex was checked if no gag intubated.  if it was RSI and goodnight.


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## AcadianExplorer1910 (Aug 25, 2015)

medichopeful said:


> The title someone has shouldn't limit how they think if they want to progress!


thanks all i know it takes me a while to learn but i love what i do and do what i love the most which is helping others. i have a instinct which needs to be worked on that when i see a unconscious patient i know they are unable to answer questions and refuse transport


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## triemal04 (Aug 25, 2015)

Tigger said:


> We don't use IN Naloxone because (and I hate this) "we are too good for IN, so we aren't buying it." Sometimes egos get in the way. So she would have gotten 0.4mg IM. If that wasn't effective, she would have been intubated and that would have been that. Our previous medical director hated Naloxone for whatever reason, and any question of polypharm OD was to be intubated. So right or wrong, that's what would have happened here.


Personally speaking, I don't see any major benefit, or need for the intranasal administration of drugs.  (with the exception of pediatric sedation, I do see some benefits there)

The only things that would make it better than an IM injection would be the speed of onset, safety, and ease of use.

That I've seen it's certainly not a faster onset than an IM shot.

If the concern is for safety, either get safety needles (there are multiple different types and all are very cheap), or learn how to give an IM injection and how to safely handle a needle; even in a combative patient that you need to sedate the risk of a needle stick, when handled appropriately, is low.

And as far as ease of use, there's no difference if the patient isn't fighting, and if they are your option is either controlling a limb (doesn't need to be an arm) or the head, which, since you need to get it into the nostril, actually becomes more difficult.

Add in that a person with a lot of fluid in the nares or one who is snorting/exhaling forcefully through the nose will effect the absorption of the drug...yeah...why bother?

Certainly doesn't hurt to have it as an option, but for people who don't, no big deal.


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## Tigger (Aug 25, 2015)

triemal04 said:


> Personally speaking, I don't see any major benefit, or need for the intranasal administration of drugs.  (with the exception of pediatric sedation, I do see some benefits there)
> 
> The only things that would make it better than an IM injection would be the speed of onset, safety, and ease of use.
> 
> ...


I agree that IN does not seem to have a lot utility in this case or others like it. However to think that "we can always get the IV or just give it IM" is poor reasoning when applied to all the medications that can be given in ways besides IV. Sometimes IN is appropriate, but we have chosen to not give ourselves that option based on shoddy reasoning. 

I would like it for frontline pediatric pain management as well as for wilderness settings. I don't see much use for Naloxone with it.


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## medichopeful (Aug 27, 2015)

AcadianExplorer1910 said:


> thanks all i know it takes me a while to learn but i love what i do and do what i love the most which is helping others. i have a instinct which needs to be worked on that when i see a unconscious patient i know they are unable to answer questions and refuse transport



You're making the right steps towards being an excellent provider by coming on this website and getting involved!  There's a lot to be learned here.


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## Angel (Aug 29, 2015)

our protocol calls for 2mg off the bat for OD's. pt ended up with 4mg IN total, and that finally woke her up enough  
(I may have said all this before)


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## NomadicMedic (Aug 29, 2015)

So, I give Narcan IN every time and it always works (when it's indicated). In the last 5 years I can't recall I case when I've pushed it IV. It's easy, it's safe and effective. No brainier to me. 

Te argument about "learn to give an IN correctly" doesn't hold water. Needle sticks happen, even with safety equipment, and the opportunity to totally eliminate that risk when dealing with a population that has a greater potential of being infectious is also a no brainier.


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## triemal04 (Aug 30, 2015)

While I do agree that IN is safer than an IM injection (it doesn't have a needle; kind of has to be) we're going to have to agree to disagree on if it's safer enough to really matter.  Like it or not, there is something that needs to be said for the proper control, and care of sharps and how they are used; many people may be pretty blasé about them, but when used in an appropriate manner, even without a safety needle, the risk of a needle stick is very, very low.  If that's the only reason for using the IN route versus the IM route it's certainly a valid reason...technically and in reality.  I just personally don't think it matters that much.

Outside of isolated cases I don't see a lot of reason to be giving narcan IV either.  IM for me baby!


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