# Administration of Narcan for AMS



## MS Medic (Dec 26, 2015)

This came up in another thread and I want to answer it without derailing the original topic so I created this one. 



DesertMedic66 said:


> Are people still giving Narcan to patients just to rule something out? Pupils are not pinpoint, respiratory drive clearly has not been depressed, and really nothing about this patient is making me think a narcotic overdose unless I am missing something...



While I don't blanket administer Narcan to all AMS, in the case of the original thread I would. If you administer Narcan and there aren't any opioids attached to the mu receptors of the CNS, then it will have no effect on the pt causing no down side to its administration. On the other hand, if the pt does have an opioid in system who symptoms might be masked, then there is benefit.  

As you stated, the pt doesn't show signs of an opioid OD and I agreed. But the stated pt is significantly ill and there was an hour long transport consisting of primarily supportive care, so I would administer Narcan to "rule out" an opioid toxidrome.


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## NomadicMedic (Dec 26, 2015)

That's just bad medicine.


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## MS Medic (Dec 26, 2015)

Why do you say that?


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## NomadicMedic (Dec 26, 2015)

Because narcan isn't even *remotely* indicated in the patient that is cited. And giving an opoid reversal agent to a patient simply because you're bored during an hour long transport and you don't know what else to do is bad medicine. That's why.


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## MS Medic (Dec 26, 2015)

I never said anything about giving it because I was bored. That type of statement is comes close to hyperbole.

Based on the information available when I originally posted that, if all other treatment possibilities have been exhausted, your options are to simply sit there and look at the pt or try something that has a significant possibility of having no effect but will only have a positive effect if does have one. In that scenario, trying the long shot isn't bad medice.


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## TXmed (Dec 26, 2015)

I don't necessarily agree with that. While an opiod OD might not be the main reason they're altered it could be adding to it. Such as septic patients on opiods or polyoverdoses. 

I once randomly gave it for a benadryl OD (suicide attempt) in which there was no indication, but it woke him up and kept me from intubating him. Come to find out he took his prescription hydro that morning like he was supposed too and it along with the benadryl contributed to the AMS


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## MS Medic (Dec 26, 2015)

TXmed said:


> I don't necessarily agree with that. While an opiod OD might not be the main reason they're altered it could be adding to it. Such as septic patients on opiods or polyoverdoses.
> 
> I once randomly gave it for a benadryl OD (suicide attempt) in which there was no indication, but it woke him up and kept me from intubating him. Come to find out he took his prescription hydro that morning like he was supposed too and it along with the benadryl contributed to the AMS



This is exactly the reasoning why I would give Narcan. I do realize it isn't likely an opioid, without the ability to run a tox screen, you can't absolutely rule it out. With that, Narcan should be considered as a later treatment possibility when everything else has been done.


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## StCEMT (Dec 26, 2015)

If there is an off chance that there is benefit and no chance of hurting the patient, how would giving it be bad medicine? TX isn't the first person I've heard say they've tried it to rule something out and it actually helped. Seems like a rather simple way to cross something off your list and narrow things down.


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## NomadicMedic (Dec 27, 2015)

Tell me why Narcan is indicated? Are you so concerned with her respiratory status that she's about to get tubed? 

Is her respiration depressed? Are her pupils pinpoint? Is there any history of opoid use? Did you see any paraphernalia around? Is nana missing a fentanyl patch? Is this really presenting as an opiate overdose? 

No. It reeks of a bleed or sepsis. (Or that other thing that tigger will mention later)

Sorry, drugs for the sake of "eh, I dunno what it can be so...why not try Narcan" seems like crap medicine to me. 

But you do you.


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## TXmed (Dec 27, 2015)

If it keeps them from buying a tube then yea. And to quote my medical director "first rule is do no harm, and that ain't gonna hurt them"


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## cruiseforever (Dec 27, 2015)

StCEMT said:


> If there is an off chance that there is benefit and no chance of hurting the patient, how would giving it be bad medicine? TX isn't the first person I've heard say they've tried it to rule something out and it actually helped. Seems like a rather simple way to cross something off your list and narrow things down.



That was the same thing we were told about using oxygen.


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## Carlos Danger (Dec 27, 2015)

Narcan for a patient in whom an opioid OD is not suspected and who is breathing just fine? Sure, why not.

I would have given a couple mg's of atropine too. You know, just in case there is some occult cholinergic toxicity going on.


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## jwk (Dec 27, 2015)

Remi said:


> Narcan for a patient in whom an opioid OD is not suspected and who is breathing just fine? Sure, why not.
> 
> I would have given a couple mg's of atropine too. You know, just in case there is some occult cholinergic toxicity going on.


Thank you!

Duh.  We administer medication for INDICATIONS, not LACK of indications.  "It couldn't hurt" is not an indication.


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## NomadicMedic (Dec 27, 2015)

Thank god. For a minute I was thinking the educated providers were actually going to agree with giving medications for the heck of it....


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## TXmed (Dec 27, 2015)

It's not like you're giving it for every healthy person. It's just a last ditch effort before having to Intubate. It's worked several times for me but I guess to each his own


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## MS Medic (Dec 27, 2015)

Fair enough. Mainly wanted to discuss it without throwing off the other thread. Task accomplished.


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## Summit (Dec 27, 2015)

Ever see a chronic pain patient get narcan when they don't need it?

Come on most borderline opiate od (anything occult is borderline) can be solved with some bagging until they clear up unless outs it's mscontin or a patch which you can find and remove.

Profound od needs the narcan.


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## gotbeerz001 (Dec 27, 2015)

I'll give Narcan for S/S of opioid OD with respiratory depression. I generally will just drop an adjunct and use capnography to determine adequate ventilation. If they are unresponsive but otherwise stable, is a nice quiet ride to the ED.


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## StCEMT (Dec 27, 2015)

cruiseforever said:


> That was the same thing we were told about using oxygen.


True. But physiologically each makes sense. Narcan competes for receptor sites, but isn't shown (not that I am aware at least) to produce any effects once it binds to the receptors in the absence of an opiate. It's just there. While I only have a basic understanding of o2 toxicity, when the radicals come into contact with another cell, we know it causes damage. Higher PO2=More radicals=more damage to cells. 

That and one of the indications in my book was coma/AMS of unknown origin. I will look up the exact wording when I get home tonight. If I don't know the origin of a pt's AMS, by what I have listed it is indicated. Other things I see might sway what I think one way or another, but either way, I don't see how it'd hurt to keep the idea in the back of your mind when going over things even if you don't use it. This is not the first time I've seen someone say they went out on a limb and it helped. But I am still learnin, so what the hell do I know, wouldn't be the first time I've been wrong.


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## SandpitMedic (Dec 27, 2015)

Suspected opioids, yes. 
Prior to intubation, yes.

Just because, no.


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## Summit (Dec 27, 2015)

StCEMT said:


> Narcan competes for receptor sites, but isn't shown (not that I am aware at least) to produce any effects once it binds to the receptors in the absence of an opiate.



That's a very simplistic assumption of patient state. Image opioid countering poly pharmacy of the stimulant variety? Or chronic pain state now out of control!


Here are adverse reactions:
http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/r?dbs+hsdb:@term+@rn+465-65-6

Most related to post surgical but many are potentially applicable pre hospital. 

*If you have no indication that a treatment it's needed, how might it hurt is every bit as important a question as how might it help. That is before you ask cost. If everything is equal it is considered best not to act in medicine unless you are desperate.*

Back in the 80s using narcan to suppress endogenous opioids that use those receptors in shock states was thought to be the next great use of narcan. But it didn't work and the risk wasn't worth "doing it just in case" not to mention cost.


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## phideux (Dec 27, 2015)

TXmed said:


> It's not like you're giving it for every healthy person. It's just a last ditch effort before having to Intubate. It's worked several times for me but I guess to each his own



The OP stated that the respiratory drive wasn't depressed, why would you even be considering dropping a tube???


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## chaz90 (Dec 27, 2015)

phideux said:


> The OP stated that the respiratory drive wasn't depressed, why would you even be considering dropping a tube???


Barely responsive to painful stimuli, excessive salivation, no intrinsic effort to clear her own airway, posturing, "near trismus" with inability to completely access the airway, and ~1 hr. transport time by ground.

Yeah, I'm absolutely going to RSI this patient.


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## ERDoc (Dec 27, 2015)

MS Medic said:


> This is exactly the reasoning why I would give Narcan. I do realize it isn't likely an opioid, without the ability to run a tox screen, you can't absolutely rule it out. With that, Narcan should be considered as a later treatment possibility when everything else has been done.


A tox screen is useless and should not change your management.  All it tells you is what the pt has taken in the last few days, not what is causing the acute issue.  Narcan, and any medication for that matter, should only be given if there are clinical indications to give it.  I haven't read the original scenario so I can't say if I would give it or not, but from the sounds of it, probably not.



Summit said:


> Ever see a chronic pain patient get narcan when they don't need it?
> 
> Come on most borderline opiate od (anything occult is borderline) can be solved with some bagging until they clear up unless outs it's mscontin or a patch which you can find and remove.
> 
> Profound od needs the narcan.



This is the part that EMS doesn't get to see.  Doing something in the ambulance can have huge consequences downstream.  There was recently a case here where EMS picked up a pt on chronic, high dose opiates from a nursing home (we won't even get into that part) who was altered. The pt was not given any additional meds over her normal meds and did not have access to anything she wasn't prescribed.  This crew hit this poor 60 something woman with 4mg IV narcan.  After they drop her off she develops horrible withdrawal (heart rate in the 150s, RR in the 30s, agitated, combative, pupils were huge) and she was no more lucid than she was when she arrived.  She was given massive amounts of dilaudid and ativan.  She ended up being intubated when she started to tire.  The admitting service tried putting a subclavian line in and dropped her lung.  She then required a chest tube.  So, this woman who was not a narcotic overdose was given a medication than doesn't do any harm because, "hey, it couldn't hurt," and ended up in opiate withdrawal, intubated and with a central line and chest tube, none of which probably would have been needed in the first place if the narcan was not given.

Never say a medication doesn't have a downside.  They all do and the effects can be disastrous.


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## CALEMT (Dec 27, 2015)

I know I'm just the EMT posting in the super cool ALS forum, but since when do you give medications that aren't clinically indicated? I thought for narcan you need opioid OD with a decreased respiratory drive. Since when do we (providers) give medications just to rule something out?


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## StCEMT (Dec 27, 2015)

Summit said:


> That's a very simplistic assumption of patient state. Image opioid countering poly pharmacy of the stimulant variety? Or chronic pain state now out of control!
> 
> 
> Here are adverse reactions:
> ...



I don't know what the patient state is in this case. I am not unaware of the potential issues associated with chronic pain. 

That was actually a pretty interesting link, thanks for sharing. 

Again, I don't know what patient state is so it may or may not be indicated. I went and looked at my book though. The two indications I had in mind from the reading are ALOC and coma of unknown origin. Which is why depending on the situation, indications I've been given, and prior experience of others it wasn't something ruled out immediately for me. Based on what indications I had been given in the text, it seems like something to keep reserved until an earlier treatment has some positive effect or I find another reason to rule it out (coma origin becomes known etc.). That being said, I am by no means saying give out Narcan to anyone and everyone "just cuz".


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## DesertMedic66 (Dec 27, 2015)

I love that my county's protocols do not even mention ALOC as a consideration for Narcan (I don't like the dosage we have to do)


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## FiremanMike (Dec 27, 2015)

DesertMedic66 said:


> I love that my county's protocols do not even mention ALOC as a consideration for Narcan (I don't like the dosage we have to do)
> 
> 
> 
> ...



Mine does

1.  Unconscious/Unknown - sugar > 60, give narcan
2.  CVA/Unconscious - In patients with decreased LOC of unknown etiology
3.  Narcan - Indications -> unconscious/unknown

Although, all three pages say to only give enough to "maintain adequate respirations".

Overall I would consider our protocol to be progressive and our medical director to be hands-on and involved, so it's not a matter of having a weak protocol.


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## Tigger (Dec 27, 2015)

For me to give a patient narcan the patient needs to have respiratory depression. The patient in the scenario is has a compromised airway but is not depressed. I do not believe those to be the same thing. Also, her pupils were fairly large.


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## medicsb (Dec 28, 2015)

I prefer to have a good, solid indication for narcan (empty bottle of percocet or a needle in the arm are preferred).  But, there have been situations where it was questionable and narcan administration saved the patient from a. intubation and/or b. an expensive work-up for altered mental status.  I prefer small doses 0.4-0.5mg at a time, so I have not had anyone spiral in to some terrible withdrawal so far.  Typically if I do this it's because they're stable (i.e. everything in normal ranges), relatively healthy (few minor problems or no PMHx), without signs of trauma, euglycemic, etc... as in there is no immediately identifiable  cause for their comatose state.  I'd say that the more comorbidities and the older they are, the more I'm going to need strong evidence of opiate intoxication.


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## FiremanMike (Dec 28, 2015)

I would be curious to hear what demographic you guys work in.  Perhaps socioeconomic strata becomes a factor that raises and lowers our respective index of suspicion and leads us to be more or less likely to administer narcan?


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## Doczilla (Dec 28, 2015)

You guys remember the old "coma cocktail"? Everyone with AMS got thiamine, D50 and narcan.

I think people still try to titrate to "awake" (read: combative, piss and vomit covered, etc), when the paradigm has shifted to respiration-driven administration.

If they're "altered" with adequate respirations, leave them alone (aside from searching for more insideous causes of AMS). I think this is especially true in polypharmacy, where removing one component while leaving the other one unopposed can have deleterious effects. Like ERdoc said, they often have to get REsedated later. What did we accomplish for them?

Edit: Spelling


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## Tigger (Dec 28, 2015)

Doczilla said:


> You guys remember the old "coma cocktail"? Everyone with AMS got thiamine, D50 and narcan.
> 
> I think people still try to titrate to "awake" (read: combative, piss and vomit covered, etc), when the paradigm has shifted to respiration-driven administration.
> 
> ...


Yes. If they are adequately breathing we just transport and provide supportive care. I don't feel as cool when I walk in and have no idea what is going on, but that's just the reality sometimes.


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## Tigger (Dec 28, 2015)

Tigger said:


> Yes. If they are adequately breathing we just transport and provide supportive care. I don't feel as cool when I walk in and have no idea what is going on, but that's just the reality sometimes.





FiremanMike said:


> I would be curious to hear what demographic you guys work in.  Perhaps socioeconomic strata becomes a factor that raises and lowers our respective index of suspicion and leads us to be more or less likely to administer narcan?


I work through a midsized city all the way to the super boonies. Same procedure.


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## gotbeerz001 (Dec 28, 2015)

FiremanMike said:


> I would be curious to hear what demographic you guys work in.  Perhaps socioeconomic strata becomes a factor that raises and lowers our respective index of suspicion and leads us to be more or less likely to administer narcan?


Oakland, CA... We give Narcan for respiratory depression with suspected narcotic OD. Our ALOC protocol directly states DO NOT administer Narcan in the absence of respiratory depression. 

Plenty of "socioeconomic strata" here.


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## DesertMedic66 (Dec 28, 2015)

FiremanMike said:


> I would be curious to hear what demographic you guys work in.  Perhaps socioeconomic strata becomes a factor that raises and lowers our respective index of suspicion and leads us to be more or less likely to administer narcan?


We cover a vast amount of areas that include multi million dollar houses, housing tracks where the individual net worth has to be over 5 million to live there, the ghetto where drug deals are going down across the street and the homie drop offs at the police/fire/EMS station, the small communities at least an hour away from anything, and several farming communities.


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## Flying (Dec 28, 2015)

We cover everything from the big urban college town to generic New Jersey suburbia to a few of the top zip codes in income.


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## NomadicMedic (Dec 28, 2015)

Huge military base, town of about 60,000 and a lot of rural. I don't dispense Narcan based on ZIP Code or how much money they have in their pocket. They get it (or don't) based on respiratory drive.


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## Chewy20 (Dec 28, 2015)

Do you also give epi when someone is stung by a bee and shows no signs of anaphylaxis?

You could ask the same question about any drug when its not actually indicated. Listen to how stupid that sounds.


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## FiremanMike (Dec 28, 2015)

Alright, the socioeconomic question was meant to elicit discussion, no reason to start posturing.

I do believe we are being a little bit too "all or nothing" with the stance that respiratory depression is the end-all, be-all decision maker for the administration of narcan.  Altered LOC, in and of itself, can have its own set of issues and potential necessity for reversal.  Is the patient so far unconscious that self maintenance of their airway may become an issue?  Is there a potential for opiate use and/or abuse?  Is the administration of narcan better for these patients than securing their airway?  If the above answers are true, then why does a respiratory rate of 12 drive your decision making process?  

None of the questions I asked have absolute answers, and neither should your approach to your patient.  Certainly unconsciousness with respiratory depression and friends saying "he used heroin" will bring me to narcan more quickly, but an absence of respiratory depression certainly doesn't take narcan completely off the table, in my book.


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## TXmed (Dec 28, 2015)

FiremanMike said:


> Alright, the socioeconomic question was meant to elicit discussion, no reason to start posturing.
> 
> I do believe we are being a little bit too "all or nothing" with the stance that respiratory depression is the end-all, be-all decision maker for the administration of narcan.  Altered LOC, in and of itself, can have its own set of issues and potential necessity for reversal.  Is the patient so far unconscious that self maintenance of their airway may become an issue?  Is there a potential for opiate use and/or abuse?  Is the administration of narcan better for these patients than securing their airway?  If the above answers are true, then why does a respiratory rate of 12 drive your decision making process?
> 
> None of the questions I asked have absolute answers, and neither should your approach to your patient.  Certainly unconsciousness with respiratory depression and friends saying "he used heroin" will bring me to narcan more quickly, but an absence of respiratory depression certainly doesn't take narcan completely off the table, in my book.




Great point !!

So I have a question now. Would anybody be comfortable transportating an altered patient with no gag reflex ? Say GCS <8? Regardless of respiratory rate, without intervention with narcan or ET tube ?


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## DesertMedic66 (Dec 28, 2015)

TXmed said:


> Great point !!
> 
> So I have a question now. Would anybody be comfortable transportating an altered patient with no gag reflex ? Say GCS <8? Regardless of respiratory rate, without intervention with narcan or ET tube ?


My protocols are extremely limited and often I am given no other choice but to do this.


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## Carlos Danger (Dec 28, 2015)

TXmed said:


> Great point !!
> 
> So I have a question now. Would anybody be comfortable transportating an altered patient with no gag reflex ? Say GCS <8? Regardless of respiratory rate, without intervention with narcan or ET tube ?



It depends, of course.

Unresponsiveness is not an emergency in itself.

How would you know they had no gag reflex, in this hypothetical scenario?


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## Carlos Danger (Dec 28, 2015)

FiremanMike said:


> *I do believe we are being a little bit too "all or nothing" with the stance that respiratory depression is the end-all, be-all decision maker for the administration of narcan.*  Altered LOC, in and of itself, can have its own set of issues and potential necessity for reversal.  Is the patient so far unconscious that self maintenance of their airway may become an issue?  Is there a potential for opiate use and/or abuse?  Is the administration of narcan better for these patients than securing their airway?  If the above answers are true, then why does a respiratory rate of 12 drive your decision making process?



Not really. 

Altered LOC is not an emergency in and of itself, despite what we've been brainwashed into believing. 

Anyone who is narcotized to the point that they have obvious airway compromise and are unresponsive to painful stimulus is almost certainly going to have noticeably depressed ventilatory drive.

To put it another way, someone who is breathing just fine is highly unlikely to be narcotized, and therefore highly unlikely to respond favorably to narcan.


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## TXmed (Dec 28, 2015)

Remi said:


> Not really.
> 
> Altered LOC is not an emergency in and of itself, despite what we've been brainwashed into believing.
> 
> ...



Well my thinking is less of a straight forward OD and more of a polypharmacy mixing benzo, narcotics, stimulants, everybody mix's alcohol with everything or having a mix of prescribed medications and medical problems such as sepsis.

There are alot of people with no or very little gag reflex and if you mix that with extensive alcohol, Xanax or sleep medication (which is becoming more popular) then you will get an unarrousable patient with intact respiratory drive, and the ability to quickly aspirate. This are patients that are candidates to get intubated in an ER because the doctor doesn't feel comfortable leaving them in a room by themselves.


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## NomadicMedic (Dec 28, 2015)

Right, but if you transport them in high Fowlers and are attentive, there is little chance of them aspirating.

However, if it was indeed true that the patient had no gag reflex and a GCS of less than 8, they would wind up getting intubated as a matter of course. They wouldn't necessarily receive Narcan though.


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## ERDoc (Dec 28, 2015)

TXmed said:


> Great point !!
> 
> So I have a question now. Would anybody be comfortable transportating an altered patient with no gag reflex ? Say GCS <8? Regardless of respiratory rate, without intervention with narcan or ET tube ?



If they cannot protect their airway for whatever reason, then we need to.  That doesn't mean they need a narcan trial before the tube unless there is a reason to believe there are opiates involved.  If it is a polypharmacy OD, then I would much rather tube the pt and let it all work out of their system than reverse the opiates and have another issue to deal with.

I'm amazed that there are still coma cocktail or coma pseudo-cocktail protocols out there.


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## TXmed (Dec 28, 2015)

DEmedic said:


> Right, but if you transport them in high Fowlers and are attentive, there is little chance of them aspirating.
> 
> However, if it was indeed true that the patient had no gag reflex and a GCS of less than 8, they would probably wind up getting intubated as a matter of course. They wouldn't necessarily receive Narcan though.



Ok, I can get behind that. But as a provider I always try to keep my patients from getting a tube if I can help it. Not really with a coma cocktail or anything like that.


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## Seirende (Dec 28, 2015)

Summit said:


> That's a very simplistic assumption of patient state. Image opioid countering poly pharmacy of the stimulant variety? Or chronic pain state now out of control!





ERDoc said:


> This is the part that EMS doesn't get to see.  Doing something in the ambulance can have huge consequences downstream.  There was recently a case here where EMS picked up a pt on chronic, high dose opiates from a nursing home (we won't even get into that part) who was altered. The pt was not given any additional meds over her normal meds and did not have access to anything she wasn't prescribed.  This crew hit this poor 60 something woman with 4mg IV narcan.  After they drop her off she develops horrible withdrawal (heart rate in the 150s, RR in the 30s, agitated, combative, pupils were huge) and she was no more lucid than she was when she arrived.  She was given massive amounts of dilaudid and ativan.  She ended up being intubated when she started to tire.  The admitting service tried putting a subclavian line in and dropped her lung.  She then required a chest tube.  So, this woman who was not a narcotic overdose was given a medication than doesn't do any harm because, "hey, it couldn't hurt," and ended up in opiate withdrawal, intubated and with a central line and chest tube, none of which probably would have been needed in the first place if the narcan was not given.
> 
> Never say a medication doesn't have a downside.  They all do and the effects can be disastrous.



I'm still at the point where the majority of my thinking is based on what I learned in initial education. The two things that were drilled into my head about Narcan were that you only give enough to get the patient breathing, because it's dangerous to wake them up, and secondly, that if it's a mixed OD such as heroin+cocaine, the patient can go into cardiac arrest if you take away the opioid that is opposing the stimulant. I think some of my podcasting MD idols would call that "a clean kill." Lesson being, only give Narcan for respiratory failure or arrest, and only enough to restore the respiratory drive.

Withdrawal in chronic pain control patients was not something that I remember being taught or thinking of myself, so thank you guys for that.​


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## FiremanMike (Dec 28, 2015)

Remi said:


> Not really.
> 
> Altered LOC is not an emergency in and of itself, despite what we've been brainwashed into believing.
> 
> ...



I'll start turfing all of my altered mental status patient's and tell the family "Remi from the internet says this isn't an emergency"..

All joking aside, you are insistent that narcan needs to be always off the table unless the respiratory rate is below a certain threshold and I'm insistent that I never speak in absolutes.  Don't assume that I give out narcan indiscriminately, but it remains a part of my potential arsenal at all times with ALOC patients.


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## SixEightWhiskey (Jan 26, 2016)

correct me if i missed it, but no one has brought up that narcan is not necessarily a benign drug. Besides withdrawal seizures and untoward affects based on size of the dose given vs. the dose of the opiate still in the system, people can have unknown hypersensitivities to it like any other medication. Adverse reactions, per the manufacturer, can include VF and cardiac arrest. I've personally seen someone go into pulmonary edema/ARDS s/p narcan administration who required emergent RSI, and ultimately ICU care. 

Anyone else have thoughts on this?


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## COmedic17 (Jan 26, 2016)

I don't give narcan -even with confirmed  opioid  use- unless they are unstable. 

If they are breathing, have a normal BP, etc I just transport them in. It's not worth possibly putting someone into seizure, getting projectile vomited on, or getting punched in the face if the patient is completely stable. 

There's even some repeat offenders that I restrain their arms prior to giving narcan, because from past experiences, I know they are going to be out for blood when they come around. 

Also food for thought- if you're going to push narcan for a depressed resp drive on an opioid OD, push the narcan BEFORE you drop the tube....I know someone who tubed first... It did not turn out well.


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## medichopeful (Jan 27, 2016)

StCEMT said:


> Narcan competes for receptor sites, but isn't shown (not that I am aware at least) to produce any effects once it binds to the receptors in the absence of an opiate. It's just there.



There's actually some literature out there about narcan use in septic shock.  

http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=76f7eee1-d524-43a4-a868-ffa9f29638a6

http://www.cochrane.org/CD004443/IN...re-needed-to-show-whether-this-reduces-deaths


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## STXmedic (Jan 27, 2016)

Narcan, because I don't know what else to do...

Coming from the guy who regularly "treats and streets" heroin users... Lol


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## wilderness911 (Feb 6, 2016)

SixEightWhiskey said:


> correct me if i missed it, but no one has brought up that narcan is not necessarily a benign drug. Besides withdrawal seizures and untoward affects based on size of the dose given vs. the dose of the opiate still in the system, people can have unknown hypersensitivities to it like any other medication. Adverse reactions, per the manufacturer, can include VF and cardiac arrest. I've personally seen someone go into pulmonary edema/ARDS s/p narcan administration who required emergent RSI, and ultimately ICU care.
> 
> Anyone else have thoughts on this?



Fascinating stuff, 68W. Thanks for sharing. I had never heard of an actual adverse reaction to narcan before, and I appreciate you taking the time to share that.


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## wilderness911 (Feb 7, 2016)

Heh...my first thought was "Why the hell would you push narcan for acute mountain sickness!?" 

Time to pound some coffee and activate the brain.


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## wilderness911 (Feb 7, 2016)

COmedic17 said:


> If they are breathing, have a normal BP, etc I just transport them in. It's not worth possibly putting someone into seizure, getting projectile vomited on, or getting punched in the face if the patient is completely stable.



Right there with you buddy. And when I do push it, I like to go nice and slow - just enough to bring back the respiratory drive, not enough to bring back the attitude. Don't always succeed in shooting the moon on that one, but when I have it has resulted in an all around more pleasant experience for all parties. I have never understood when medics slam a full bolus of narcan - it's a recipe for trouble.

Also, I have yet to push narcan for any patient without confidence they were ODing on opiates. Pupillary miosis, diaphoretic skin, apnea or inadequate ventilations always provide a strong tell. I also shine a light up the nostrils to look for residue indicating insufflation and do a quick check in the usual IV drug user sites for additional indications. Usually there are plenty of signs that an opiate is involved, and it is rare (in my experience at least) that a patient manages to OD on oral opiates. Pro tip: blue smurf boogers result from roxicodone insufflation and are a pretty easy way to figure out what happened, if that was the flavor of the day. In a number of my patients roxicodone has been the culprit, as it is cheap, widely available, instant release, and free from any acetaminophen to deter abuse.


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## ExpatMedic0 (Feb 7, 2016)

Who here is old enough to remember the coma cocktail? It use to be a thing... Then evidence base medicine came along and took away all the fun.


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## NomadicMedic (Feb 7, 2016)

ExpatMedic0 said:


> Who here is old enough to remember the coma cocktail? It use to be a thing... Then evidence base medicine came along and took away all the fun.



Sure. I also remember using EOAs, a lifePak 5 and a jaw screw. 

I don't miss any of that "fun".


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## wilderness911 (Feb 7, 2016)

DEmedic said:


> Sure. I also remember using EOAs, a lifePak 5 and a jaw screw.
> 
> I don't miss any of that "fun".



What's a jaw screw?


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## NomadicMedic (Feb 7, 2016)

wilderness911 said:


> What's a jaw screw?


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