# Narcan or not



## rmabrey

The other night my partner and I get called to an unconscious 20 y/o male, bystanders cant tell if hes breathing or not.  We get on scene and the Volly FD for the area has every truck they run on scene. 

Walk in, Pt is unconscious, on a backboard w/ OP airway and FD is bagging. Bystanders have been on scene approx 15 minutes and only came to check on the PT., no idea how long he has been down. GCS 3, cyanotic, has a pulse, pupils constricted and non reactive. Bystanders st Pt. has overdosed on klonopin and seroquel before and has talked about doing it again, those are the only meds we find in the apartment. 

Partner establishes an IV, 250 NS, and gives Versed, attempt 1 size 7.0 ET unsuccessful attempt 2 size 6.0 unsuccessful. I get a combitube, Etomidate given en route. As we are loading the patient up his brother shows up and tells us he probably took Opana.

Without going into all the boring details of what the Doctor, Pts mother (also a doctor) and Fireman who is a medic student said to us and the lab results, given the information presented would you have given narcan?


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## fast65

Yup, I would have.


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## exodus

Sure. Almost All indications there, no contra's. I wouldn't have tubed him either.


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## ArcticKat

Yup, I would have given it as soon as I had a line started.  I tried giving it intranasally once but it didn't seem to work as well.  As soon as we started a line and gave her Narcan IV she woke right up.


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## rmabrey

Ill go ahead and add the rest before I go to work.

Pts mom, and medic student said we should have given Narcan. ER Doc asked why it wasnt given and my partner told him.

No opiates were found in his system and he went to ICU within 30 minutes. The hospital never gave Narcan.


So my next question is, why constricted pupils? Dont Benzos dilate the pupils?


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## Aidey

Yup, I would have tried narcan. Our medical director gets a little irritated when we RSI people without giving narcan and checking their blood sugar first. Something about doing a highly invasive procedure without attempting to fix the underlying problem first. 

Also, what makes you think this was from the klonopin? Read up on the side effects of a seroquel OD.


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## Smash

I don't see any indications to give naloxone.  Sure, he has miosis and respiratory depression, but there are more things than just opioids that will cause this.  I realise that the brother turned up after you managed his airway, but that is just bad luck, you can only act on the information that you find at the time, and you found nothing to make you suspect opioids were part of the problem.

Also not knowing how long he has been down, you are taking a big gamble that he has not had a prolonged hypoxia and a blue brain as a result.  There's nothing worse than bringing a patient up to a GCS of 8, having them combative and difficult to manage, and also doing their ICP no favours.  I've seen it happen a few times, it's not pretty (I may even have been responsible for it a couple of times...)

I would elect in this patient to ventilate, and depending on how well that was working and how far it was to hospital, RSI and intubate.  I think versed only and then forcing a tube is a very bad idea.

I think giving narcan before RSI is a bit silly, as it has then eliminated one of your induction agents (if you choose to use an opioid: I do) and definitely one of the maintenance agents, making the job more difficult and the patient more unhappy with having a tube down his throat.  Blood sugar check though, absolutely.


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## ArcticKat

I can see where you're coming from Smash but I respectfully disagree for the following reasons:

1. Narcan can work on more than just opoids, including benzos.  Just not as effectively.
http://het.sagepub.com/content/early/2010/06/22/0960327110374972

2. He's already overdosed on a benzo, why give him more for an RSI?

3. His GCS was 3, was an RSI even required?  Did he have a gag reflex? 
(I don't know this, it's not in the OP)

4. If the Narcan is ineffective, then he will still have a GCS of 3, intubate then.  In this particular case, intubation didn't work anyways.

I feel it would be appropriate to be using a BVM to support resps while giving Narcan, it will provide sufficient oxygenation until such time as the Narcan is determined ineffective.  About 1 minute.  It would take that long just to set up the intubation anyways.


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## exodus

Also, who's to say he didn't go to the corner, buy 20 vicodin's, down them in the car, and walked inside to die in his home. He wouldn't of wanted the evidence there, that would make it easier for people to save him. He wanted an out and may have thought it through.

(Not speaking on this specific case, but in general about OD's)

He presented with an opiod OD, Imminent resp arrest, pinpoint pupils, aloc. Only thing missing was the actual fact he took opiods.


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## Handsome Robb

ArcticKat said:


> 3. His GCS was 3, was an RSI even required?  Did he have a gag reflex?
> (I don't know this, it's not in the OP)



This was my first thought. 

I'd give the narcan, personally. 

If he truly had a GCS of 3 RSI shouldn't be required so I'm not super worried about antagonizing narcs that I would give for induction/maintenance.

There is no direct evidence of opiate OD but the pt has a hx of attempted OD and threatened to repeat the attempt (per friends on scene) + pinpoint pupils + respiratory depression/imminent respiratory arrest + ALOC. I say give it. Risk vs. Benefits.


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## EMT11KDL

From the information provided, Yes I would have given Narcan also.  You had indications for it.  

In the field, we never get the compete history or story of what happened.  We make split second decisions on the signs and symptoms that are present at the time.  he met the qualifications for narcan.


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## Fish

Narcan before even thinking of a tube for sure, and even if that didn't work you didn't need to give Versed to this guy before intubating. He already had a GCS of 3. Narcan is sooooooo harmless, don't be sceeeeerd.


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## Fish

NVRob said:


> This was my first thought.
> 
> I'd give the narcan, personally.
> 
> If he truly had a GCS of 3 RSI shouldn't be required so I'm not super worried about antagonizing narcs that I would give for induction/maintenance.
> 
> There is no direct evidence of opiate OD but the pt has a hx of attempted OD and threatened to repeat the attempt (per friends on scene) + pinpoint pupils + respiratory depression/imminent respiratory arrest + ALOC. I say give it. Risk vs. Benefits.



I'd still give succs or Roc, but no need for the Versed of Etomidate.

This Pt. should of Never been tube in the first place.


But I am curious, what DID the Fire Medic say on scene?


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## DrParasite

I'm curious.... what is the downside to administering Narcan in this patient?  Other than the cost of the medication, if you give it and it doesn't work, what have you lost?  what are the negative side effects? are there any?


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## Smash

ArcticKat said:


> I can see where you're coming from Smash but I respectfully disagree for the following reasons:
> 
> 1. Narcan can work on more than just opoids, including benzos.  Just not as effectively.
> http://het.sagepub.com/content/early/2010/06/22/0960327110374972
> 
> 2. He's already overdosed on a benzo, why give him more for an RSI?
> 
> 3. His GCS was 3, was an RSI even required?  Did he have a gag reflex?
> (I don't know this, it's not in the OP)
> 
> 4. If the Narcan is ineffective, then he will still have a GCS of 3, intubate then.  In this particular case, intubation didn't work anyways.



1.  Notwithstanding a small study from Tehran, I doubt that you (or anyone) would consider narcan to be a standard of care in the treatment of benzodiazepine overdose, never mind the seroquel. 

2.  Whether you elect to give more benzo should you choose to RSI this patient is not the point.  The point is whether you give narcan or intubate. Even if you elect to intubate this patient without RSI, opioids are still required for maintenance of the tube once it is placed.

3.  As I'm sure you are aware, a GCS of 3 does not mean no gag reflex.  I'm not too keen to find out by causing an eruption of Volcano Budpizzarus when I whack a cold blade down there.

4.  Indeed this is true.  If it were reasonable to expect that he would respond to narcan, and ended up not responding, then fair enough, we play the hand we are dealt.  However I have no reasonable expectation that a person who appears to have overdosed on benzodiazepines and atypical antipsychotics will respond to narcan.  This then creates a problem when or if we elect to intubate.

I would like to think that anyone who is intubating anything other than corpses is doing it with a decent RSI protocol.  This includes an opioid at some stage, usually a short acting one like fentanyl, remifentanyl or sufentanyl during induction and something like fentanyl or morphine for ongoing analgesia.  I realise that the evidence for opioids having an effect on mortality when used in RSI is non-existent, however I still consider them to be important.  Intubation is a painful procedure, so whether or not the elimination of sympathetic tone to mitigate ICP spikes is effective or not, it seems more than reasonable to include an opioid during induction for humane reasons if nothing else.
Opioids are also vital for ongoing analgesia post intubation.  In fact analgesia is the most important part of the post intubation package, with sedation being the added bonus for the patient.
So if we go giving narcan to a patient we have no reason to expect a response to, we are setting ourselves up to provide sub-standard care subsequently.



exodus said:


> Also, who's to say he didn't go to the corner, buy 20 vicodin's, down them in the car, and walked inside to die in his home. He wouldn't of wanted the evidence there, that would make it easier for people to save him. He wanted an out and may have thought it through.
> 
> (Not speaking on this specific case, but in general about OD's)
> 
> He presented with an opiod OD, Imminent resp arrest, pinpoint pupils, aloc. Only thing missing was the actual fact he took opiods.



No, he didn't present with an opioid overdose, he presented with CNS depression in the setting of a presumed overdose on benzodiazepines and atypical antispychotics.  

Who can say he didn't take vicodins?  No-one.  Who can say he hasn't had a brainstem infarct?  Who can say he hasn't been hit on the head with a small meteorite and his hair is hiding the wound?  Speculation is fun, but the facts of the matter as stated by the OP is that there is no evidence of opioid overdose.


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## Fish

I still say Pin point pupils is reason enough to push Narcan before you are going to intubate someone, period. I don't need a needle hanging out of someones arm, or an empty bottle of morphine to convince me that maybe i should try Narcan before intubating someone, seeing as if the Narcan works well hey I no need to intubate, if it doesn't, well then that rules that out and now we are dealing with something else.


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## firecoins

rmabrey said:


> Walk in, Pt is unconscious, on a backboard w/ *OP airway *and FD is bagging.



I am confused.  The patient was given an oral airway prior to arrival. So the patient didn't have a gag reflex.  Pt could be tubed without the need for more benzos.  If more benzos are needed to maintain, they should be given enroute to the hospital.


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## ArcticKat

firecoins said:


> I am confused.  The patient was given an oral airway prior to arrival. So the patient didn't have a gag reflex.



Whoa, nice catch, I shoulda caught that.


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## rmabrey

Im tired and in the middle of 5 straight 12's so when I get a break I will answer what questions I can. As for tubing the patient and versed all I can say is the dreaded word PROTOCOL. 

Whether or not my partner should have given Narcan ( i would have with my limited knowledge) I wont fault him cause he is much smarter than I and he followed protocol........He either got lucky or knew what he was doing. 


Found out today he also took a chemotherapy drug of some sorts. He was transferred to a psychiatric facility today.


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## McGoo

firecoins said:


> I am confused.  The patient was given an oral airway prior to arrival. So the patient didn't have a gag reflex.  Pt could be tubed without the need for more benzos.  If more benzos are needed to maintain, they should be given enroute to the hospital.



Not necessarily. I have had a pt with GCS 3, took an OPA with no complaints, but gagged when the tube hit his cords.


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## medicsb

I guess I can claim Team Narcan on this one.

I still think that a known overdose of one drug suggests a possible overdose of another.  It isn't a stretch for someone to also OD on an opiate, but the pontine hemorrhage or a small meteor is a little more remote.  Narcan in the appropriate doses is likely to be harmless, and if it works, then even better - you've avoided a tube (at least temporarily).

Anyhow, the problem with naloxone be can overcome with a larger dose of an opiate as naloxone is a competitive antagonist.  Considering the massive doses of fentanyl that can be given, I don't think a dose 2-3 times higher than usual will cause many problems in the intubated, non-trauma patient.


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## McGoo

If the patient is being ventilated adequately with an OpA and a BVM, I don't see an immediate need for narcan, but I would probably still give it. I would most likely give 1mg IM, see what happens, give more if it has an effect. But I wouldn't give enough to wake him up, only enough to maintain a patent airway.


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## Sodapop

Assuming the Airway and BVM was getting good ventilation I would have tried the Narcan as soon as I had the IV.  If the Narcan did not work then I would have intubated the patient.

Since he had an airway in place upon arrival at the ER I would have to think that would impact whether they try Narcan or not.

I could be wrong here but as I understand it Narcan will block the effects the drug is having on the respiratory system and return the patients respiration to  more normal level.  It does not remove the effecting drug so that is still in the system and as the Narcan wears off the respiration's will decrease again and an additional dose of Narcan will be required to sustain proper respiration's.  In the given situation the patient was delivered to the hospital with a controlled airway so the use of Narcan is not necessary and if it was a drug OD causing the resp. depression the drug can run it's course, leave the system and the resp. would return and the airway could be removed.

So I would have tried it but I also see where not using it could be deemed appropriate as well assuming the airway can be controlled.


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## Fish

Sodapop said:


> Assuming the Airway and BVM was getting good ventilation I would have tried the Narcan as soon as I had the IV.  If the Narcan did not work then I would have intubated the patient.
> 
> Since he had an airway in place upon arrival at the ER I would have to think that would impact whether they try Narcan or not.
> 
> I could be wrong here but as I understand it Narcan will block the effects the drug is having on the respiratory system and return the patients respiration to  more normal level.  It does not remove the effecting drug so that is still in the system and as the Narcan wears off the respiration's will decrease again and an additional dose of Narcan will be required to sustain proper respiration's.  In the given situation the patient was delivered to the hospital with a controlled airway so the use of Narcan is not necessary and if it was a drug OD causing the resp. depression the drug can run it's course, leave the system and the resp. would return and the airway could be removed.
> 
> So I would have tried it but I also see where not using it could be deemed appropriate as well assuming the airway can be controlled.



Right and wrong, the more people you can prevent from being intubated and kept off of a ventilator, the better. Narcan should ahve been used, a call review at our system would have been generated for something like this if Narcan was not given since it is a pretty clear cut reason to give it.


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## Sodapop

Fish said:


> Right and wrong, the more people you can prevent from being intubated and kept off of a ventilator, the better. Narcan should ahve been used, a call review at our system would have been generated for something like this if Narcan was not given since it is a pretty clear cut reason to give it.



Agreed. I would have gone with Narcan initially but if the patient already had a tube in place I would have thought twice to prevent a patient from pulling out an airway and possibly causing more trauma. So I can see where on arrival at the ER that Narcan may not have been considered.


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## Fish

Sodapop said:


> Agreed. I would have gone with Narcan initially but if the patient already had a tube in place I would have thought twice to prevent a patient from pulling out an airway and possibly causing more trauma. So I can see where on arrival at the ER that Narcan may not have been considered.



Oh, right... I thought, nevermind I misread your post.

No way would I push narcan on a dood whose toob'd


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## Smash

Fish said:


> Right and wrong, the more people you can prevent from being intubated and kept off of a ventilator, the better. Narcan should ahve been used, a call review at our system would have been generated for something like this if Narcan was not given since it is a pretty clear cut reason to give it.



As this has been resurrected: this call also would have generated a review in my system, but only if I gave a drug that is not indicated for a problem that doesn't exist.  That is unlikely to happen though, because I treat what I can reasonably deduce to be wrong with the patient.  I don't treat pinpoint pupils.  Maybe that is just me, but then I was educated to practice medicine.


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## Fish

Smash said:


> As this has been resurrected: this call also would have generated a review in my system, but only if I gave a drug that is not indicated for a problem that doesn't exist.  That is unlikely to happen though, because I treat what I can reasonably deduce to be wrong with the patient.  I don't treat pinpoint pupils.  Maybe that is just me, but then I was educated to practice medicine.



Right, the history and patient presentation screams Narcan.


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## Handsome Robb

Fish said:


> Right, the history and patient presentation screams Narcan.



+1

It would have been flagged for review here as well. Well most all intubations are reviewed anyways.


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## Smash

Fish said:


> Right, the history and patient presentation screams Narcan.



The history of not having taken opioids?  Oh, ok then I will keep in mind that not having been reported to have had opioids, having no physical evidence of such, and having a couple of symptoms that can be attributed to the drugs the patient has taken, or to a range of other medical conditions rather than opiods means that opiods have been taken.

Good to know, that's a practice changing pearl of wisdom there.


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## Fish

Smash said:


> The history of not having taken opioids?  Oh, ok then I will keep in mind that not having been reported to have had opioids, having no physical evidence of such, and having a couple of symptoms that can be attributed to the drugs the patient has taken, or to a range of other medical conditions rather than opiods means that opiods have been taken.
> 
> Good to know, that's a practice changing pearl of wisdom there.



Glad to know I could help learn you something 

If this call doesn't scream use of Narcan, well then... I don't know what to tell you. Present this scenario to every ER Doc you see in the Next 30 days and see who they agree with, me or you.


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## Smash

It will no doubt be an interesting conversation:  

Me:  "Doc, if you have a patient with a benzo and atypical antipsychotic overdose, you should give them narcan right?"

Doctor:  "Ahhhh.... what?

Me:  "You know, someone who has taken too many benzos and seroquel, narcan will fix them right up won't it?"

Doctor:  "Sorry, are you f**ked in the head?  Has somebody put you up to this, or are you actually retarded?"

Me:  "No, really, narcan is the go to drug in situations that have no history of opioid overdose, but some CNS depression: some dude on the interwebs who calls himself a paramedic told me so"

Doctor (backing away slowly towards the duress button)  "Sure, whatever you say buddy..."

Me:  "Hey guys, are you security?  Cool!  Is that a Taser?  Neat, I've always wanted to AAAAAHHHHHHHHHHHHHH!"


I will actually do that, I'm back on nights this week, so I will genuinely go ahead and see what the ER docs say.  I will head up to ICU and ask the ICU docs as well.

Do you seriously go through life in EMS just picking a symptom and giving a drug that may be completely inappropriate?  I know EMS in the US, broadly speaking, is in a :censored::censored::censored::censored: state, but that really scares me.  Describe for me how this call "screams narcan", because I really am struggling to see it.


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## Handsome Robb

Pinpoint pupils, respiratory distress/arrest, ALOC, suspected OD of pharmaceuticals + a history of previous attempts I don't see why it would be inappropriate to trial narcan. There's no opioids in the house but who's to say he didn't have them in the wrong container seeing as he could very well buy them on the street. Opioids are a commonly abused drug and pretty readily available illegally. 

I see your point Smash but still. Plus if you deliver the question to a doctor like that how do you suspect to get the time of day from them? You'd be leading them with your questions.


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## Fish

Smash said:


> It will no doubt be an interesting conversation:
> 
> Me:  "Doc, if you have a patient with a benzo and atypical antipsychotic overdose, you should give them narcan right?"
> 
> Doctor:  "Ahhhh.... what?
> 
> Me:  "You know, someone who has taken too many benzos and seroquel, narcan will fix them right up won't it?"
> 
> Doctor:  "Sorry, are you f**ked in the head?  Has somebody put you up to this, or are you actually retarded?"
> 
> Me:  "No, really, narcan is the go to drug in situations that have no history of opioid overdose, but some CNS depression: some dude on the interwebs who calls himself a paramedic told me so"
> 
> Doctor (backing away slowly towards the duress button)  "Sure, whatever you say buddy..."
> 
> Me:  "Hey guys, are you security?  Cool!  Is that a Taser?  Neat, I've always wanted to AAAAAHHHHHHHHHHHHHH!"
> 
> 
> I will actually do that, I'm back on nights this week, so I will genuinely go ahead and see what the ER docs say.  I will head up to ICU and ask the ICU docs as well.
> 
> Do you seriously go through life in EMS just picking a symptom and giving a drug that may be completely inappropriate?  I know EMS in the US, broadly speaking, is in a :censored::censored::censored::censored: state, but that really scares me.  Describe for me how this call "screams narcan", because I really am struggling to see it.



The conversation would go nothing like that, infact I did you a favour. I printed out the OPs scenario, presented to the ER Docs on lastnight and wouldn't you know it, they all said you'd be crazy to not give Narcan before attempting intubation. If I recall you the only person on this thread who disagrees, also I am friggin right. The OP posted this thread because they intubated a patient without giving narcan when it was indicated and got crap for it, that is why he posted it on here. So, how are you going to legitimately argue a point with me when it turns out I am right that the patient needed Narcan?

For you to say after reading this scenario that you fail to see how he needs narcan is scary. Your being tunnel visioned into thinking just because benzos are all that it is "known" that the patient took, well then must be all that he has in his system. Dude has a known drug history, pin point pupils, ALOC enough to want to intubate, decreased resp. rate. It is known that he has already taken a bunch of benzos, Medic units in the US don't carry ramazicon for benzo overdoses(Yes I amfriggin aware Narcan doesn't touch Narcotic overdoses) But what I am saying, is I would still push narcan all day every day on this patient because he is unresponsive and unable to give you a full history and whith what he is presenting with tells me there is possibly more to this. And guess what? I would be right all day every day if I did push Narcan, how do I know? Because that is why the OP posted this thread, he wanted our opinions on a patient that they did not give narcan to that they should of and once they got to the ER, they quickly found out why they should of given Narcan.

Also, if you ever asked questions in the way that you just posted. Well then of course YOU are going to get the answer YOU were looking for. Hand them a print out of the scenario as written by the OP, and let them decided without your opinion.

nobody disagrees that this patient obviously has ingested Benzos and anti-pshycotics, but that is not the reason for the Narcan in this particular patient.


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## Sodapop

Well said Fish

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## Melclin

I would find this a difficult situation. 

The two things that bother me here are down time and losing the ability to tube this guy. 

Downtime: We have no idea how long he's been down for. I would have thought there was a pretty damn good chance of hypoxic brain injury here. In that case, we wanna keep down, not bring him up. I see this as being a similar scenario to junkie x crashing his car on the way home from a heroin enthusiast convention. GCS 6-10, head injury, pinpoint pupils, resp depression. That guy is not getting narcan. Not a chance. I think you can make a decent argument that this is a similar situation.  

The tube: You narc this guy and he comes good? Well problem solved. But what if he doesn't? What if he doesn't blink an eyelid. Now you need to tube him and you can't provide proper analgesia. Whats worse is if he does come up a little, combative but altered with a hypoxic brain injury, or polypharm OD with opiates and other things, then you have a nasty situation.

The way I see it is that narcan is for uncomplicated opiate overdoses. Low chance of hypoxic brain injury, nil involvement of other substances with no other signs of illness/injury (aspiration, head injury etc). This guy has almost certain poly pharmed himself, so already narcan is low on my list of things to do, and there is a reasonable chance of hypoxic brain injury. Add to that, the fact that there isn't actually any evidence of opiate ingestion. I'd say no to narcan. Wait for Intensive care to turn up, if they wanna tube him, then great, I haven't ruined their party. If they reckon narcan is worth a shot, then that's their choice. 

I've had a couple of similar pts most of whom got narcan at some stage with varrying degrees of success. Its a judgement call, as always.


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## Fish

Melclin said:


> I would find this a difficult situation.
> 
> The two things that bother me here are down time and losing the ability to tube this guy.
> 
> Downtime: We have no idea how long he's been down for. I would have thought there was a pretty damn good chance of hypoxic brain injury here. In that case, we wanna keep down, not bring him up. I see this as being a similar scenario to junkie x crashing his car on the way home from a heroin enthusiast convention. GCS 6-10, head injury, pinpoint pupils, resp depression. That guy is not getting narcan. Not a chance. I think you can make a decent argument that this is a similar situation.
> 
> The tube: You narc this guy and he comes good? Well problem solved. But what if he doesn't? What if he doesn't blink an eyelid. Now you need to tube him and you can't provide proper analgesia. Whats worse is if he does come up a little, combative but altered with a hypoxic brain injury, or polypharm OD with opiates and other things, then you have a nasty situation.
> 
> The way I see it is that narcan is for uncomplicated opiate overdoses. Low chance of hypoxic brain injury, nil involvement of other substances with no other signs of illness/injury (aspiration, head injury etc). This guy has almost certain poly pharmed himself, so already narcan is low on my list of things to do, and there is a reasonable chance of hypoxic brain injury. Add to that, the fact that there isn't actually any evidence of opiate ingestion. I'd say no to narcan. Wait for Intensive care to turn up, if they wanna tube him, then great, I haven't ruined their party. If they reckon narcan is worth a shot, then that's their choice.
> 
> I've had a couple of similar pts most of whom got narcan at some stage with varrying degrees of success. Its a judgement call, as always.



You give Narcan and still feel you need to intubate? Well then I would use Succs and a Benzo to Sedate. Since Narcan does not effect Benzos...

I understand your point, but also it made me think....... How many Narc ODs have I been on(lots I used to work in the Heroin Capital) and out of all of those how many of them did I know there down time, if I had to guess like 20% maybe? Still we gave Narcan, and still an ER Doc would have given Narcan. I have brought in a few Poly Pharm patients as well that I in no way suspected had taken any Narcotics, and depending on the Doc I have seen them administer Narcan as an attempt to rule some stuff out while they wait for a tox screen.


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## Fish

Fish said:


> The conversation would go nothing like that, infact I did you a favour. I printed out the OPs scenario, presented to the ER Docs on lastnight and wouldn't you know it, they all said you'd be crazy to not give Narcan before attempting intubation. If I recall you the only person on this thread who disagrees, also I am friggin right. The OP posted this thread because they intubated a patient without giving narcan when it was indicated and got crap for it, that is why he posted it on here. So, how are you going to legitimately argue a point with me when it turns out I am right that the patient needed Narcan?
> 
> For you to say after reading this scenario that you fail to see how he needs narcan is scary. Your being tunnel visioned into thinking just because benzos are all that it is "known" that the patient took, well then must be all that he has in his system. Dude has a known drug history, pin point pupils, ALOC enough to want to intubate, decreased resp. rate. It is known that he has already taken a bunch of benzos, Medic units in the US don't carry ramazicon for benzo overdoses(Yes I amfriggin aware Narcan doesn't touch Narcotic overdoses) But what I am saying, is I would still push narcan all day every day on this patient because he is unresponsive and unable to give you a full history and whith what he is presenting with tells me there is possibly more to this. And guess what? I would be right all day every day if I did push Narcan, how do I know? Because that is why the OP posted this thread, he wanted our opinions on a patient that they did not give narcan to that they should of and once they got to the ER, they quickly found out why they should of given Narcan.
> 
> Also, if you ever asked questions in the way that you just posted. Well then of course YOU are going to get the answer YOU were looking for. Hand them a print out of the scenario as written by the OP, and let them decided without your opinion.
> 
> nobody disagrees that this patient obviously has ingested Benzos and anti-pshycotics, but that is not the reason for the Narcan in this particular patient.



I made a typo when I said "Narcan doesn't work on Narcotics" I ment Narcan doesn't touch Benzos.


----------



## Smash

Fish said:


> If I recall you the only person on this thread who disagrees, also I am friggin right.



You'll have to do better than logical fallacies.  Also: ego much?



> The OP posted this thread because they intubated a patient without giving narcan when it was indicated and got crap for it, that is why he posted it on here. So, how are you going to legitimately argue a point with me when it turns out I am right that the patient needed Narcan?



Except not:





rmabrey said:


> Pts mom, and medic student said we should have given Narcan. ER Doc asked why it wasnt given and my partner told him.
> No opiates were found in his system and he went to ICU within 30 minutes. The hospital never gave Narcan.


An unconnected Dr (doctor of what?) and a medic student opined that they should have given narcan.  That doesn't sound like getting crap to me.  The fact that no narcan was given by the hospital at any stage suggests that the decision to withhold narcan was correct in the eyes of the treating physicians also.



> For you to say after reading this scenario that you fail to see how he needs narcan is scary. Your being tunnel visioned into thinking just because benzos are all that it is "known" that the patient took, well then must be all that he has in his system.



Indeed I do treat on what I know, or what I can reasonably conclude.  I cannot reasonably conclude that this patient has had an overdose of opioids.  I can make suppositions all day long, but it doesn't help in the management of patients.  The presence of pinpoint pupils alone is hardly definitive for opioid overdose.

I'll posit another scenario:  65 year old female, history of hypertension, hypercholestremia, AF, osteoarthritis.  Found unresponsive in bed, HR 50, BP 90/50, resp rate 6, pupils pinpoint, GCS 3 and peripherally cyanosed.  Do you give narcan?



> Dude has a known drug history, pin point pupils, ALOC enough to want to intubate, decreased resp. rate. It is known that he has already taken a bunch of benzos, Medic units in the US don't carry ramazicon for benzo overdoses(Yes I amfriggin aware Narcan doesn't touch Narcotic overdoses) But what I am saying, is I would still push narcan all day every day on this patient because he is unresponsive and unable to give you a full history and whith what he is presenting with tells me there is possibly more to this. And guess what? I would be right all day every day if I did push Narcan, how do I know? Because that is why the OP posted this thread, he wanted our opinions on a patient that they did not give narcan to that they should of and once they got to the ER, they quickly found out why they should of given Narcan.



They found out by the ER not giving narcan as well and the pt being sent to ICU for the polypharmacy overdose?  I think you might need to re-read the thread, particularly the original post.  The OP has never stated that he got in trouble for anything.  Personally I think they should have got in trouble for poor airway management attempting to intubate the patient, but it sounds as if they may be bound by protocol for that anyway.



> nobody disagrees that this patient obviously has ingested Benzos and anti-pshycotics, but that is not the reason for the Narcan in this particular patient.



So even if I were to humour you, and admit that, despite the lack of any compelling evidence to support the theory, there is a chance that opioids have been taken:  what can you reasonably expect to occur to happen when you give narcan to a polypharmacy overdose?



> I have brought in a few Poly Pharm patients as well that I in no way suspected had taken any Narcotics, and depending on the Doc I have seen them administer Narcan as an attempt to rule some stuff out while they wait for a tox screen.



Doctors practicing bad medicine is hardly an excuse for us practicing bad medicine.  I've seen doctors refusing to give analgesia to patients with abdo pain, putting non-rebreathers on normoxic chest pains, neglecting to give sedation and analgesia after RSI... the list goes on.


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## boingo

Smash said:


> I'll posit another scenario:  65 year old female, history of hypertension, hypercholestremia, AF, osteoarthritis.  Found unresponsive in bed, HR 50, BP 90/50, resp rate 6, pupils pinpoint, GCS 3 and peripherally cyanosed.  Do you give narcan? QUOTE]
> 
> Other than your reduced ability to manage pain w/opiate analgesia, what would be the down side?  I had a similar case about a year ago, with added hx of depression, no opiates in residence.  A trial of Narcan reversed the event, pt woke and admitted to taking a large amount of Oxycodone.
> 
> The other way that call would have played would have been an un needed intubation, CT scan and ICU admit, although with the ability to add Fentanyl or your opiate of choice to round out her analgesia/sedation.
> 
> Not saying the other course of action would be "wrong" per se, it's just a different approach.
> 
> Although us American medics are a pack of retards, the physician level of providers for the most part are not.  FWIW


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## Fish

boingo said:


> Smash said:
> 
> 
> 
> I'll posit another scenario:  65 year old female, history of hypertension, hypercholestremia, AF, osteoarthritis.  Found unresponsive in bed, HR 50, BP 90/50, resp rate 6, pupils pinpoint, GCS 3 and peripherally cyanosed.  Do you give narcan? QUOTE]
> 
> Other than your reduced ability to manage pain w/opiate analgesia, what would be the down side?  I had a similar case about a year ago, with added hx of depression, no opiates in residence.  A trial of Narcan reversed the event, pt woke and admitted to taking a large amount of Oxycodone.
> 
> The other way that call would have played would have been an un needed intubation, CT scan and ICU admit, although with the ability to add Fentanyl or your opiate of choice to round out her analgesia/sedation.
> 
> Not saying the other course of action would be "wrong" per se, it's just a different approach.
> 
> Although us American medics are a pack of retards, the physician level of providers for the most part are not.  FWIW
> 
> 
> 
> 
> Haha
Click to expand...


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## DrParasite

Sort of related, what are the side affects of administering Narcan on a person who is not overdosing on an opiate?


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## Dwindlin

DrParasite said:


> Sort of related, what are the side affects of administering Narcan on a person who is not overdosing on an opiate?



If the patient is opiate dependent it can cause an acute withdrawal (which is uncomfortable but not lethal).

It has been shown to cause an acute sympathetic reaction (including cases of v-fib/v-tach) but these instances have only been in post-op patients who already had a history of cardiac disease (so was it the narcan?)

OUtside of this not much (nausea is the most common).

I must say I disagree with Smash on this one, there is very little harm in giving the presented patient Narcan, as the analgesia post-induction argument is moot in my opinion.  Narcan is a competitive antagonist, meaning it can be overcome with more narcotics.  In the setting of post-intubation sedation morphine and fentanyl can both be ran at 150/hr (mg and mcg respectively).  This is WELL more than enough to overcome the Narcan and provide analgesia.


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## Fish

Dwindlin said:


> If the patient is opiate dependent it can cause an acute withdrawal (which is uncomfortable but not lethal).
> 
> It has been shown to cause an acute sympathetic reaction (including cases of v-fib/v-tach) but these instances have only been in post-op patients who already had a history of cardiac disease (so was it the narcan?)
> 
> OUtside of this not much (nausea is the most common).
> 
> *These are side affects to someone who HAS had an opiate overdose, Parasite was askin what the side affects are if you give it to someone who has not taken any opiates at all*
> 
> I must say I disagree with Smash on this one, there is very little harm in giving the presented patient Narcan, as the analgesia post-induction argument is moot in my opinion.  Narcan is a competitive antagonist, meaning it can be overcome with more narcotics.  In the setting of post-intubation sedation morphine and fentanyl can both be ran at 150/hr (mg and mcg respectively).  This is WELL more than enough to overcome the Narcan and provide analgesia.



*Agreed, but what I am failing to see here is. Why can we still not achieve sedation when intubating even if we have given Narcan? Do other systems not use IV Versed as a sedative performing an RSI? If dosed properly with a Benzo then a narcotic is not needed, am I wrong?*


----------



## DrParasite

Exactly Fish.  Lets say we are bored at the station one night, someone starts an IV on me, and administers 2 mg of Narcan.  No drugs in my system  what will happen to me?  are there any side effects?  (and no, we don't start IVs on coworkers and give narcan just because we are bored).

Following that line of thinking, if I find a man unresponsive on the ground, with pinpoint pupils, and he has no opiates in his system (but I don't know this at the present time), and I give narcan, what will happen?  will anything happen?  will anything detrimental happen?  or will it do absolutely nothing to the patient?

so if it won't hurt the patient, and might (snowballs chance here) help the patient, what is the problem with giving it?


----------



## Smash

Dwindlin said:


> I must say I disagree with Smash on this one, there is very little harm in giving the presented patient Narcan, as the analgesia post-induction argument is moot in my opinion.  Narcan is a competitive antagonist, meaning it can be overcome with more narcotics.  In the setting of post-intubation sedation morphine and fentanyl can both be ran at 150/hr (mg and mcg respectively).  This is WELL more than enough to overcome the Narcan and provide analgesia.



You certainly "could" run heroic amounts of morphine or fentanyl, but I have a couple of issues with that.  
One: if your transport time is longer than a few minutes, how many people actually carry 20 odd ampoules of morph or fentanyl?  My transport times are typically 30-60 minutes, so it quickly becomes logistically problematic to take this approach.  So why not save yourself the issue?
Two:  The "can't hurt" mentality typically leads to things that do indeed hurt.  Like O2 for everyone for example.  But more importantly it completely misses the point of actually examining and treating the patient.  Real life is not like Princeton-Plainsboro.  We can't just start giving crap to rule out things that have next to no likelihood of being present.  (And it's never sarcoidosis)

If someone calls an ambulance because they feel generally weak and crappy, you don't go giving calcium gluconate just in case it's hyperkalemia.  We don't automatically give someone who is sweaty dextrose just in case they are having a hypo.  We assess them, we gather all the info we can, and when we have a reasonable working diagnosis, we go ahead and treat with a reasonable expectation that we are on the right track.  At least, this is how medicine works in my world.  

Sure, the risks of naloxone may be less than some other medications, but it is still symptomatic of lazy, poorly educated, ineffective and potentially dangerous practice.  The patient in the OP didn't need random drugs squirted into him given the manifest issues that this could cause, he needed some airway management, some ventilation (by whatever means one considers most appropriate, not necessarily intubation) and some transport.
The OP achieved this, even though I think the airway management was sub-optimal.



Fish said:


> *Agreed, but what I am failing to see here is. Why can we still not achieve sedation when intubating even if we have given Narcan? Do other systems not use IV Versed as a sedative performing an RSI? If dosed properly with a Benzo then a narcotic is not needed, am I wrong?*



In a word, yes.  Analgesia is a vital, non-negotiable part of intubation and post intubation care.  The sedation is the icing on the cake, the added bonus to make the patient a little happier.  Fentanyl based anesthesia, primarily using large doses of fentanyl (or remifentanil, sufentanil) and little else (a small concentration of a volatile, or maybe a little midazolam or etomidate) is a common sight in OR, particularly in cardiac anesthesia.
Also, I'm curious whether you will address any of the other points I made.


----------



## Fish

Smash said:


> You certainly "could" run heroic amounts of morphine or fentanyl, but I have a couple of issues with that.
> One: if your transport time is longer than a few minutes, how many people actually carry 20 odd ampoules of morph or fentanyl?  My transport times are typically 30-60 minutes, so it quickly becomes logistically problematic to take this approach.  So why not save yourself the issue?
> Two:  The "can't hurt" mentality typically leads to things that do indeed hurt.  Like O2 for everyone for example.  But more importantly it completely misses the point of actually examining and treating the patient.  Real life is not like Princeton-Plainsboro.  We can't just start giving crap to rule out things that have next to no likelihood of being present.  (And it's never sarcoidosis)
> 
> If someone calls an ambulance because they feel generally weak and crappy, you don't go giving calcium gluconate just in case it's hyperkalemia.  We don't automatically give someone who is sweaty dextrose just in case they are having a hypo.  We assess them, we gather all the info we can, and when we have a reasonable working diagnosis, we go ahead and treat with a reasonable expectation that we are on the right track.  At least, this is how medicine works in my world.
> 
> Sure, the risks of naloxone may be less than some other medications, but it is still symptomatic of lazy, poorly educated, ineffective and potentially dangerous practice.  The patient in the OP didn't need random drugs squirted into him given the manifest issues that this could cause, he needed some airway management, some ventilation (by whatever means one considers most appropriate, not necessarily intubation) and some transport.
> The OP achieved this, even though I think the airway management was sub-optimal.
> 
> 
> 
> In a word, yes.  Analgesia is a vital, non-negotiable part of intubation and post intubation care.  The sedation is the icing on the cake, the added bonus to make the patient a little happier.  Fentanyl based anesthesia, primarily using large doses of fentanyl (or remifentanil, sufentanil) and little else (a small concentration of a volatile, or maybe a little midazolam or etomidate) is a common sight in OR, particularly in cardiac anesthesia.
> Also, I'm curious whether you will address any of the other points I made.



I will try, you POSTED A LOT! And when I attempted to respond twice yesterday we got toned out for calls so I gave up. And right now is study time for a class.


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## systemet

Fish said:


> Right, the history and patient presentation screams Narcan.



I respect your opinion, but disagree with you, the history and presentation scream he overdosed on seroquel and klonopin again.

I would also be hesitant to give narcan in this situation, and in my previous job was encouraged to just intubate mixed overdoses even if there was a strong possibility that an opiate was involved, unless I was certain that it was an isolate opiate overdose.

My experience on this forum and others, has been that providers that work in areas where there is a greater amount of illict IV opiate/opiod use are more likely to give narcan in borderline situations, and are more likely to be supported by their local medical control.  Those of use who work in areas where opiate / opiod use is less common, tend to be more conservative.


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## Fish

systemet said:


> My experience on this forum and others, has been that providers that work in areas where there is a greater amount of illict IV opiate/opiod use are more likely to give narcan in borderline situations, and are more likely to be supported by their local medical control.  Those of use who work in areas where opiate / opiod use is less common, tend to be more conservative.



Very good point, were I came from it was a common drug. Sometimes going out of service so that we can restock because the 4 preloads that we carried on the ambulance got used. Also, the Docs were more Liberal with it.


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## systemet

Fish said:


> Very good point, were I came from it was a common drug. Sometimes going out of service so that we can restock because the 4 preloads that we carried on the ambulance got used. Also, the Docs were more Liberal with it.



Maybe you can give some input on another question that's come up then?

A lot of people seem to have the impression that an absence of improved respirations or level of consciousness with a single 0.4mg dose of narcan IV, is a rule-out for opiate / opiod intoxication.  This is the idea of "diagnostic narcan".

My limited experience has been that even what I'd consider quite large doses of narcan seem to be ineffective against some opiates / opiods, for example methadone, or darvon.  It used to be that some years back when narcan protocols were a little more aggressive, and often 2mg was a standard IV dose, and 4mg was being given IM, that we still used to see patients that would require several doses.

* What's your experience been?  Because I find myself compelled to point out to people that a lack of response to 0.4mg of narcan is pretty meaningless (at least in my opinion).  

I realise what I'm asking for is anecdotal experiences, which most of us don't value too highly, but I'm just interested at to whether you, or anyone else agrees or disagrees with this.


----------



## Smash

Fish said:


> I will try, you POSTED A LOT! And when I attempted to respond twice yesterday we got toned out for calls so I gave up. And right now is study time for a class.



Fair enough I do tend to rattle on a bit.


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## Fish

systemet said:


> Maybe you can give some input on another question that's come up then?
> 
> A lot of people seem to have the impression that an absence of improved respirations or level of consciousness with a single 0.4mg dose of narcan IV, is a rule-out for opiate / opiod intoxication.  This is the idea of "diagnostic narcan".
> 
> My limited experience has been that even what I'd consider quite large doses of narcan seem to be ineffective against some opiates / opiods, for example methadone, or darvon.  It used to be that some years back when narcan protocols were a little more aggressive, and often 2mg was a standard IV dose, and 4mg was being given IM, that we still used to see patients that would require several doses.
> 
> * What's your experience been?  Because I find myself compelled to point out to people that a lack of response to 0.4mg of narcan is pretty meaningless (at least in my opinion).
> 
> I realise what I'm asking for is anecdotal experiences, which most of us don't value too highly, but I'm just interested at to whether you, or anyone else agrees or disagrees with this.



I would agree that it is not, 0.4mg I have seen this small of an amount work on pain management patients and heroin sometimes. But on the flip side I have had to give 4mg for it to work. I don't see 0.4mg as being "diagnostic"


----------



## Fish

Smash said:


> Fair enough I do tend to rattle on a bit.



As a side note, I would be stoked if that picture in your avatar is really you! I dig the Fro!


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## systemet

Fish said:


> As a side note, I would be stoked if that picture in your avatar is really you! I dig the Fro!



Seconded.


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## Dwindlin

Smash said:


> You certainly "could" run heroic amounts of morphine or fentanyl, but I have a couple of issues with that.
> One: if your transport time is longer than a few minutes, how many people actually carry 20 odd ampoules of morph or fentanyl?  My transport times are typically 30-60 minutes, so it quickly becomes logistically problematic to take this approach.  So why not save yourself the issue?
> Two:  The "can't hurt" mentality typically leads to things that do indeed hurt.  Like O2 for everyone for example.  But more importantly it completely misses the point of actually examining and treating the patient.  Real life is not like Princeton-Plainsboro.  We can't just start giving crap to rule out things that have next to no likelihood of being present.  (And it's never sarcoidosis)
> 
> If someone calls an ambulance because they feel generally weak and crappy, you don't go giving calcium gluconate just in case it's hyperkalemia.  We don't automatically give someone who is sweaty dextrose just in case they are having a hypo.  We assess them, we gather all the info we can, and when we have a reasonable working diagnosis, we go ahead and treat with a reasonable expectation that we are on the right track.  At least, this is how medicine works in my world.
> 
> *Sure, the risks of naloxone may be less than some other medications, but it is still symptomatic of lazy, poorly educated, ineffective and potentially dangerous practice.*  The patient in the OP didn't need random drugs squirted into him given the manifest issues that this could cause, he needed some airway management, some ventilation (by whatever means one considers most appropriate, not necessarily intubation) and some transport.
> The OP achieved this, even though I think the airway management was sub-optimal.



I wouldn't suggest running these amounts pre-hospital.  In this area it is completely acceptable to maintain adequate sedation post-intubation and allow the E.D. to start analgesia (and frankly we don't have protocols for it).  

Again, in this area an overdose is rarely one drug, and rarely am I told everything they ingested.  I can not count the number of times I have been in this exact situation (absolutely no objective evidence outside of exam) and a couple mg of Narcan brought them around enough to avoid a tube.  The benefit in this case FAR outweighs the risks in my opinion (and the opinion of my medical director as he would be very angry if I brought in an overdose, whom I tubed w/o at least a trial of Narcan).  

I don't expect you to ever agree with me, and that's fine, that is one of the greatest benefits of public forums.  But I would hope you realize the bolded statement is a gross over generalization.  Maybe you can trust your patients and their family where you work, here I rarely can, so yes I play the odds and believe me it has worked out in my favor FAR more than the opposite.


----------



## Remeber343

Smash said:


> As this has been resurrected: this call also would have generated a review in my system, but only if I gave a drug that is not indicated for a problem that doesn't exist.  That is unlikely to happen though, because I treat what I can reasonably deduce to be wrong with the patient.  I don't treat pinpoint pupils.  Maybe that is just me, but then I was educated to practice medicine.




They aren't saying they are treating pinpoint pupils, they are treating the whole picture.  As previously states, hx of poss. OD's, and the fact that he did take some meds, and as others have said, he may have OD on opioids, whose to say he didn't?  Try before you pry man, no need to go shoving a tube down someones throat if it could have been fixed with something as simple as narcan.  I'm not saying dont prepare for intubation, have everything ready in case its needed, but to jump straight to that w/o considering anything is kind of scary imo.  I much rather try to fix the underlying problem then having to have this pt intubated and have to go through all the issuies that might occur with that.


----------



## Fish

Remeber343 said:


> They aren't saying they are treating pinpoint pupils, they are treating the whole picture.  As previously states, hx of poss. OD's, and the fact that he did take some meds, and as others have said, he may have OD on opioids, whose to say he didn't?  Try before you pry man, no need to go shoving a tube down someones throat if it could have been fixed with something as simple as narcan.  I'm not saying dont prepare for intubation, have everything ready in case its needed, but to jump straight to that w/o considering anything is kind of scary imo.  I much rather try to fix the underlying problem then having to have this pt intubated and have to go through all the issuies that might occur with that.



Agreed


----------



## emspgh

Smash said:


> I don't see any indications to give naloxone.  Sure, he has miosis and respiratory depression, but there are more things than just opioids that will cause this.  I realise that the brother turned up after you managed his airway, but that is just bad luck, you can only act on the information that you find at the time, and you found nothing to make you suspect opioids were part of the problem."
> 
> When a pt has respiratory depression, and miosis, especially with a history of some kind of OD (be it with benzos, but the risk still applies that maybe he switched to narcs), then by all means, narcan the patient. If he wakes up, and you can avoid intubation, then perfect. Yes, it can be great in the field, but it increases morbidity and mortality in the long run. Intubation should not be the first step in a patient who can breathe, or is apneic when medications like narcan are available. There's no harm in bagging after giving narcan to see if it works.
> 
> I know the post mentioned that the bystanders couldn't tell if the patient was breathing or not, but does anyone know if the patient actually was?


----------



## chaz90

emspgh said:


> Smash said:
> 
> 
> 
> I don't see any indications to give naloxone.  Sure, he has miosis and respiratory depression, but there are more things than just opioids that will cause this.  I realise that the brother turned up after you managed his airway, but that is just bad luck, you can only act on the information that you find at the time, and you found nothing to make you suspect opioids were part of the problem."
> 
> When a pt has respiratory depression, and miosis, especially with a history of some kind of OD (be it with benzos, but the risk still applies that maybe he switched to narcs), then by all means, narcan the patient. If he wakes up, and you can avoid intubation, then perfect. Yes, it can be great in the field, but it increases morbidity and mortality in the long run. Intubation should not be the first step in a patient who can breathe, or is apneic when medications like narcan are available. There's no harm in bagging after giving narcan to see if it works.
> 
> I know the post mentioned that the bystanders couldn't tell if the patient was breathing or not, but does anyone know if the patient actually was?
> 
> 
> 
> 
> Necro post man. I don't think anyone is actively reading this and remembering the 2+ year old call.
Click to expand...


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## emspgh

chaz90 said:


> emspgh said:
> 
> 
> 
> Necro post man. I don't think anyone is actively reading this and remembering the 2+ year old call.
> 
> 
> 
> 
> Okay, I just clicked and read it. No harm, no foul.....
Click to expand...


----------

