# Nasal Narcan



## medservguru88 (Sep 23, 2012)

hi. I'm a new EMT Basic Starting with a company on tuesday. During the orientation the boss lady was talking about how nasal narcan is about to be accepted by my state. Im wondering if any of yall have ever used this and if so, how effective is it in comparison to injected narcan?


----------



## rwik123 (Sep 23, 2012)

medservguru88 said:


> hi. I'm a new EMT Basic Starting with a company on tuesday. During the orientation the boss lady was talking about how nasal narcan is about to be accepted by my state. Im wondering if any of yall have ever used this and if so, how effective is it in comparison to injected narcan?



Yeah I have. It's fairly comparable to IV push....most often more convenient too if you don't already have a line. You can always give the initial dose IN, then switch over to IV once established. Not sure on the actual times of effect and resp drive return, but I know there close.   

It also reduces the incidence of needle sticks in a generally assumed high risk HIV population.


----------



## NomadicMedic (Sep 23, 2012)

Use it all the time. It rocks.


----------



## STXmedic (Sep 23, 2012)

n7lxi said:


> Use it all the time. It rocks.



This.


----------



## medservguru88 (Sep 23, 2012)

rwik123 said:


> Yeah I have. It's fairly comparable to IV push....most often more convenient too if you don't already have a line. You can always give the initial dose IN, then switch over to IV once established. Not sure on the actual times of effect and resp drive return, but I know there close.
> 
> It also reduces the incidence of needle sticks in a generally assumed high risk HIV population.


I'd be more cautious with hep c with the injected drug crowd than HIV


----------



## TransportJockey (Sep 23, 2012)

Our basics here have had it for a while, in addition to SQ/IM Narcan... I like it, but don't like that a lot of our basics give 1mg per nare... I don't want to wake up the druggie, just get them breathing.


----------



## Tigger (Sep 23, 2012)

TransportJockey said:


> Our basics here have had it for a while, in addition to SQ/IM Narcan... I like it, but don't like that a lot of our basics give 1mg per nare... I don't want to wake up the druggie, just get them breathing.



That is unfortunately the way my company is instructing basics to administer it. I have no interest in giving the full 2mg as a first line dose, hopefully some leeway is possible.


----------



## NYMedic828 (Sep 23, 2012)

Our protocols are

IV 0.4mg increments titrated to 2mg.

IM/IN 0.8mg titrated to 2mg.


I find that 0.2mg IV and 0.4mg IN/IM is often plenty.


----------



## sirengirl (Sep 23, 2012)

NYMedic828 said:


> I find that 0.2mg IV and 0.4mg IN/IM is often plenty.



I watched an ER doc assume care for an OD patient that a rescue brought in. When asked why the medic did not give narcan, the medic said,

"Her RR is fine, pulse normal, color good, she's responsive to sternal rub... I didn't want to wake her up, she's good."

Doc then proceeds to give 0.2mg narcan IVP.... patient starts to rouse, grumbling and swatting at nothing. Doc then says, 

"Push the other half."

ER medic and I spent the next hour pinning her to the bed as she thrashed, screamed, and flailed, while they force-inserted a Foley, and then she proceeded to use her feet to pull the Foley out, still fully inflated.

Good times. :glare: I will never go to that hospital.


----------



## TransportJockey (Sep 23, 2012)

sirengirl said:


> I watched an ER doc assume care for an OD patient that a rescue brought in. When asked why the medic did not give narcan, the medic said,
> 
> "Her RR is fine, pulse normal, color good, she's responsive to sternal rub... I didn't want to wake her up, she's good."
> 
> ...



I've worked ER as a tech and seen that. And it's why I make hospital sign for the patient before I let them pull crap like that.


----------



## NomadicMedic (Sep 23, 2012)

I was dispatched on a cardiac arrest the other day. The EMT that arrived before me was freaking out, screaming that he needed my LUCAS. I sent him out to my truck to get it. By the time he came back, i had squirted a mg up the guys nose and he was sitting up. 



IN Narcan is a medics best friend.


----------



## NYMedic828 (Sep 23, 2012)

n7lxi said:


> I was dispatched on a cardiac arrest the other day. The EMT that arrived before me was freaking out, screaming that he needed my LUCAS. I sent him out to my truck to get it. By the time he came back, i had squirted a mg up the guys nose and he was sitting up.
> 
> 
> 
> IN Narcan is a medics best friend.



Should of said to the EMT, "So I guess we aren't going that initial assessment thing anymore?"


----------



## NomadicMedic (Sep 24, 2012)

NYMedic828 said:


> Should of said to the EMT, "So I guess we aren't going that initial assessment thing anymore?"



My sarcasm isn't typically appreciated by the BLS providers here.


----------



## Remeber343 (Sep 24, 2012)

n7lxi said:


> My sarcasm isn't typically appreciated by the BLS providers here.



Eh, I figure the good ones shouldn't care and it should motivate the bad ones to get their act together..


----------



## JPINFV (Sep 24, 2012)

n7lxi said:


> I was dispatched on a cardiac arrest the other day. The EMT that arrived before me was freaking out, screaming that he needed my LUCAS. I sent him out to my truck to get it. By the time he came back, i had squirted a mg up the guys nose and he was sitting up.
> 
> 
> 
> IN Narcan is a medics best friend.


----------



## the_negro_puppy (Sep 25, 2012)

We have no choice but to give 1.6,g I.M, however our protocols are flexible in that they prefer we do this only after ensuring adequate oxygenation / ventilation first.

Having said that, narc overdoses are very rare here. We do not have a huge heroin scene in my city, nor is prescription drug abuse as rampant as in the U.S. I have had one narc overdose in nearly 3 years. Bystander was doing CPR when we arrived, she was apeoeic however still had a tachy pulse, apparently IV oxycodone.

1 minute of ventilation with BVM and she came up swinging lol.


----------



## Sandog (Sep 25, 2012)

the_negro_puppy said:


> Having said that, narc overdoses are very rare here. We do not have a huge heroin scene in my city, nor is prescription drug abuse as rampant as in the U.S. I have had one narc overdose in nearly 3 years. Bystander was doing CPR when we arrived, she was apeoeic however still had a tachy pulse, apparently IV oxycodone.
> 
> 1 minute of ventilation with BVM and she came up swinging lol.



I wonder why this is so. I mean what are you guys doing right? Why is it that the U.S. can not follow?


----------



## the_negro_puppy (Sep 25, 2012)

Sandog said:


> I wonder why this is so. I mean what are you guys doing right? Why is it that the U.S. can not follow?



I can't answer that. I can say that the population of Aus is around 22 million, and the U.S 300 million. Statistically you guys have a higher rate of drug abuse and given your geographic location and huge demand for drugs its no surprise that they flood the cities of the U.S

Heroin is scarce here because there is not a huge demand and we are quite geographically separated from Afghanistan etc. If I were a trafficker I would probably aim for the U.S as a market rather than Aus.

As per prescription drugs I guess it comes down to culture. Docs aren't as lenient in prescribing opiates/opioids here but then again your health system is much more privatised- when people are paying large amounts to see physicians they probably feel pressured to prescribe things. In a sense your health system is more commercial and "customer" focused.

Although Australia and the U.S are very very similar it seems the U.S is more extreme with its problems such as gang violence, crime and drug addiction. I'm 100% sure that if we had 10 times the population I would see far more opioid overdoses.


----------



## NYMedic828 (Sep 25, 2012)

Well, there goes the neighborhood. This just out by my county (not NYC)


*Suspected Opioid Overdose Protocol for BLS Providers AAREMS, Monroe Livingston, Mountain Lakes, REMO, Suffolk and Nassau

Patient must have suspected narcotic overdose AND respiratory depression. Naloxone is not given to rule out opiate use.

I. Perform initial assessment. If ventilatory status is inadequate (patient is cyanotic, altered mental status, respiratory rate less than 10) support respirations according to Respiratory/Arrest Failure protocol.

II. Check blood glucose (BG must be greater than 65)

III. Determine potential for narcotic overdose (at least one of the following) a. History of overdose from bystanders
b. Paraphernalia consistent with opiate/narcotic use
c. Medical history consistent with opiate/narcotic use
d. Respiratory depression with pinpoint pupils
IF I, II and III are true THEN proceed with NALOXONE as follows:

IV. Open sealed NALOXONE container and remove one unit dose of Naloxone a. Examine for appropriate labeling, expiration and appearance
b. Attach mucosal atomizer device (MAD) to the syringe
V. Insert MAD into LEFT nostril and inject HALF the medication Repeat into the RIGHT nostril

VI. Continue to support ventilation as appropriate while initiating transport to closest appropriate Facility

VII. Document vital signs every 5 minutes

VIII. If patient's respiratory rate does not increase to greater than 10 within 10 minutes of initial Naloxone administration, repeat with second unit dose of Naloxone
Relative Exclusion Criteria: (Medical Control Option)
Cardiopulmonary Arrest
Recent seizure activity either by report or signs of recent seizure activity (oral trauma,
urinary incontinence) Pediatric patients
Opiate use for therapeutic purposes prescribed by a physician Evidence of nasal trauma, nasal obstruction and/or epistaxis*

I certainly do not approve of the protocol due to the dosing. 1mg per nare is ridiculous. If we aren't capable of understand titration at a BLS level and fully understanding what we are doing then we shouldn't be permitted to administer the medication at all.

Taking shortcuts by making it as simple as possible instead of providing the proper education is not acceptable in my book.


----------



## Aidey (Sep 25, 2012)

I wonder what would happen if you injected it into the right nostril first, lol.


----------



## NYMedic828 (Sep 25, 2012)

Aidey said:


> I wonder what would happen if you injected it into the right nostril first, lol.


----------



## eprex (Sep 25, 2012)

NYMedic828 said:


>



:rofl:

That gif is the best


----------



## mycrofft (Sep 25, 2012)

medservguru88 said:


> I'd be more cautious with hep c with the injected drug crowd than HIV



Many many many of either "Crowd" has *both* hepatitis and HIV, along with other things like nasal colonization of staph bacteria, and increasingly STD's .


----------



## mycrofft (Sep 25, 2012)

Quoting NYMedic828 re basics giving narcan by protocol:

"I certainly do not approve of the protocol due to the dosing. 1mg per nare is ridiculous. If we aren't *capable of understand titration at a BLS level* (emphasis added..mycrofft) and fully understanding what we are doing then we shouldn't be permitted to administer the medication at all.

Taking shortcuts by making it as simple as possible instead of providing the proper education is not acceptable in my book."

Maybe that is one case of why basics can't give much beyond sugar, oxygen and topical antiseptics in most areas. Titration is not taught, and is not as simple as giving X dose a number of times until sign Y appears. 

Narcan is not mother's milk and any drug given by a practitioner demands that the indications and measures of/for Plan-B are taught in case the med doesn't work or makes things worse.


----------



## NYMedic828 (Sep 25, 2012)

mycrofft said:


> Quoting NYMedic828 re basics giving narcan by protocol:
> 
> "I certainly do not approve of the protocol due to the dosing. 1mg per nare is ridiculous. If we aren't *capable of understand titration at a BLS level* (emphasis added..mycrofft) and fully understanding what we are doing then we shouldn't be permitted to administer the medication at all.
> 
> ...



Agree 100%.

These cases are where you start either drawing or erasing the line between BLS and ALS.

Either keep it as basic as possible, or teach what is necessary to appropriately perform the task in an educated manor. Taking shortcuts by making the procedure as brainless as possible is not acceptable. 

It is shocking to me that a physician would even allow administration of a medication in an essentially careless manor.


----------



## mycrofft (Sep 25, 2012)

MD's were prescribing Valium, Phenobarbitol, Talwin, THalidomide, and earlier yet, radium salts and laudanum with abandon before their drawbacks were fully appreciated.

Erasing the line: urban: yes, maybe. Rural and frontier: not unless a way is found to even approach the degree of EMS coverage they have now, which is piddlin' little in some areas (which also have no hospitals to speak of).


----------



## NYMedic828 (Sep 25, 2012)

I made a point on my county forum about my dislike of the dosing and this is what someone posted back...

"The IN dose is 1mg/nare (2mg total). With IN, not all of that is going to make it into the bloodstream. Some of it will run down the throat, some will run down the face, and some will just stick to nose hair."


----------



## NomadicMedic (Sep 25, 2012)

Apparently people on your county forum are idiots?


----------



## NYMedic828 (Sep 25, 2012)

n7lxi said:


> Apparently people on your county forum are idiots?


----------



## mycrofft (Sep 26, 2012)

But a good point about the drawbacks of nasal introduction. What of the pt has rhinorreah, epistaxis? If it is atomized, nasal hair _can_ be an obstacle. If the nasal solution is ingested, will it still work, or work the same?

SO many times I wish hypodermic introduction of meds was still pursued as it once was; if the technique is aseptic and the drug correct in selection, dose and route (IM versus sub q, versus intradermal, versus IV), then the drug is not only on its way, but various formulations (such as with penicillin) can make it a timed release so serial doses are not required.


----------



## SubiEmt (Sep 30, 2012)

medservguru88 said:


> hi. I'm a new EMT Basic Starting with a company on tuesday. During the orientation the boss lady was talking about how nasal narcan is about to be accepted by my state. Im wondering if any of yall have ever used this and if so, how effective is it in comparison to injected narcan?


 Seen the medics do it. Restrain your OD patents :rofl:


----------



## Tigger (Sep 30, 2012)

SubiEmt said:


> Seen the medics do it. Restrain your OD patents :rofl:



For actually?


----------



## NYMedic828 (Sep 30, 2012)

If you have to restrain your overdosed patient you are improperly administering the drug.

If you know it's an opiate induced condition and respiratory status is sufficient and they are just knocked out, leave em be.

If used as a diagnostic tool or to restore respiratory status then titration to desired effect is key. Narcan takes very minimal doses and has a very rapid onset regardless of route. IV in my experience is near instant. IN/IM maybe 30-120 seconds. The goal should be to restore sufficient breathing and keep them relatively sedated if possible.

Keep in mind narcan only lasts around 30-60 minutes and morphine for example can last 2-4 hours. You must monitor the patient even if you think the condition is resolved because try can fall back into it easily in some cases.


It would behoove you to research how opioid receptors work and then you will understand narcan. Knowing all of the effects of narcotics can be very beneficial in ruling out a suspected overdose prior to medicating your patient. (Look up Mu,kappa,delta receptors)


----------



## SubiEmt (Sep 30, 2012)

Tigger said:


> For actually?



No they didn't actually do it. I was joking only because most (including this particular pt.) did become combative. Awesome first had experience to see how fast the drug took effect! Pt reps were almost non existent, cynotic around the lips. Of course bagged him, medics administered the drug IN, and almost instant improvement. Really cool stuff.


----------



## Handsome Robb (Oct 1, 2012)

SubiEmt said:


> No they didn't actually do it. I was joking only because most (including this particular pt.) did become combative. Awesome first had experience to see how fast the drug took effect! Pt reps were almost non existent, cynotic around the lips. Of course bagged him, medics administered the drug IN, and almost instant improvement. Really cool stuff.



Still sounds like they gave too much.

We can give IN near an but it's a pain in the *** since they are needled prefills, no leur-locks  Everything else has them except the narcan...


----------



## SubiEmt (Oct 1, 2012)

NVRob said:


> Still sounds like they gave too much.
> 
> We can give IN near an but it's a pain in the *** since they are needled prefills, no leur-locks  Everything else has them except the narcan...


 Hmm, next time I'll have to ask what the protocol is for dosage. Or I'm sure you can answer that for me? You said they were pre-filled? Sounds like there's maybe already a set dosage? Does the medication differ per county depending on where you work? Sorry for the 20 questions, but you have my attention now!


----------



## nemedic (Oct 1, 2012)

At a service I used to work for in MA, they had IN Narcan in pre filled 2mg syringes with this little nose plug adapter. For basics, the requirement/training was 1mg up each nare.


----------



## Medic Tim (Oct 1, 2012)

SubiEmt said:


> Hmm, next time I'll have to ask what the protocol is for dosage. Or I'm sure you can answer that for me? You said they were pre-filled? Sounds like there's maybe already a set dosage?



The key is titration. Just because it comes supplied at a certain concentration does not mean you have to give it all. If you protocol says 2 mg it does not mean give 2 mg to every overdose pt just because the protocol said so. There is no need to give the pt 2 mg when less than half of that will most likely work. Then again I work in a system that as long as we are in scope and doing something to benefit the pt we are good to go.


----------



## NYMedic828 (Oct 1, 2012)

SubiEmt said:


> Hmm, next time I'll have to ask what the protocol is for dosage. Or I'm sure you can answer that for me? You said they were pre-filled? Sounds like there's maybe already a set dosage? Does the medication differ per county depending on where you work? Sorry for the 20 questions, but you have my attention now!



Everywhere I have been, carries Prefilled 2ml bristojets at 1mg/ml. On rare occasion I have seen Prefilled syringes and closed vials.

This is one of those things where the protocol should be manipulated to suit your patient. Giving 1mg(half a vial of 1ml) per nostril is improper. It really only takes 0.2-4mg IV, 0.4-8mg IN/IM in my experience to achieve desired effect without creating an angry junky. IN/IM can have more sparatic absorption rates and impeding factors than IV so the dose varies more.

The dose is the same, or should be the same, everywhere you go. I've never seen narcan not come in a 1mg/1ml solution.


----------



## Medic Tim (Oct 1, 2012)

NYMedic828 said:


> Everywhere I have been, carries Prefilled 2ml bristojets at 1mg/ml. On rare occasion I have seen Prefilled syringes and closed vials.
> 
> This is one of those things where the protocol should be manipulated to suit your patient. Giving 1mg(half a vial of 1ml) per nostril is improper. It really only takes 0.2-4mg IV, 0.4-8mg IN/IM in my experience to achieve desired effect without creating an angry junky. IN/IM can have more sparatic absorption rates and impeding factors than IV so the dose varies more.
> 
> The dose is the same, or should be the same, everywhere you go. I've never seen narcan not come in a 1mg/1ml solution.



Agreed.



We use 0.4mg/ml amps.


----------



## SubiEmt (Oct 1, 2012)

nemedic said:


> At a service I used to work for in MA, they had IN Narcan in pre filled 2mg syringes with this little nose plug adapter. For basics, the requirement/training was 1mg up each nare.



I see, so maybe it is a tad bit different everywhere? Interesting stuff, thanks for the reply!



Medic Tim said:


> The key is titration. Just because it comes supplied at a certain concentration does not mean you have to give it all. If you protocol says 2 mg it does not mean give 2 mg to every overdose pt just because the protocol said so. There is no need to give the pt 2 mg when less than half of that will most likely work. Then again I work in a system that as long as we are in scope and doing something to benefit the pt we are good to go.


Makes sense! So 2mg is the MAX dose we're looking at here. Would you ever give maybe half, then depending on the pt. status administer the rest? Or just make the call to give Xmg's up front and that's it? Thanks in advanced for the tips here.


----------



## Medic Tim (Oct 1, 2012)

SubiEmt said:


> I see, so maybe it is a tad bit different everywhere? Interesting stuff, thanks for the reply!
> 
> 
> Makes sense! So 2mg is the MAX dose we're looking at here. Would you ever give maybe half, then depending on the pt. status administer the rest? Or just make the call to give Xmg's up front and that's it? Thanks in advanced for the tips here.



The biggest issue with these types of things is education. The education of a Medic is not enough to cover all that we do. Yet they are giving basic providers Medic skills where the education is next to nothing. 

If you are going to deviate or do something different from your standing orders you need to be able to back up what and why you did it. In my system we can treat our pts without forcing them into a black and white protocol. I do not know your qa/qi policies but I have heard that some areas treat their protocols as the bible so to speak and not following it to the letter will get you in trouble.


----------



## Aidey (Oct 1, 2012)

Just for the record some types of opiates can require very large doses of narcan because the half life of the opiate is so much longer than that of narcan.


----------



## NYMedic828 (Oct 1, 2012)

Aidey said:


> Just for the record some types of opiates can require very large doses of narcan because the half life of the opiate is so much longer than that of narcan.



Or the efficacy is just massive in cases like fentanyl requiring 6-10mg of narcan.


To whoever called it a "nose plug thingy," its called a muscosal atomizer... Otherwise known as a MAD.

Your standard prefilled narcan IN kit has these parts.


----------



## Devilz311 (Oct 2, 2012)

n7lxi said:


> I was dispatched on a cardiac arrest the other day. The EMT that arrived before me was freaking out, screaming that he needed my LUCAS. I sent him out to my truck to get it. By the time he came back, i had squirted a mg up the guys nose and he was sitting up.
> 
> 
> 
> IN Narcan is a medics best friend.



It's sad that I have experienced this multiple times... My last one was dispatched as an OD, about 30 seconds out we get an update from BLS on scene of CPR in progress. 20-ish y/o female with snoring respirations at about 4-6/min. I asked why they were performing CPR and I was told "well we hooked up the AED and it said no shock advised, start CPR... so we did." They were amazed when she miraculously came around to 0.4mg IV. 

...And this particular individual is a CPR instructor... :huh:


----------



## andyman0291 (Oct 6, 2012)

ive used it more times than i can count... i work in one of the worst areas for heroin od's in the state.


----------



## lsmft (Oct 12, 2012)

rwik123 said:


> Yeah I have. It's fairly comparable to IV push....most often more convenient too if you don't already have a line. You can always give the initial dose IN, then switch over to IV once established. Not sure on the actual times of effect and resp drive return, but I know there close.
> 
> It also reduces the incidence of needle sticks in a generally assumed high risk HIV population.



What's your guys' max dose out there? Here if you give the 1mg/nare you'd need MCEP to authorize another 0.4 IV/SC. Hate to have them come out punching, which is why I like more controlled doses. Although I guess I'm going off the assumption your protocols are 1mg/nare as well.


----------



## NomadicMedic (Oct 13, 2012)

Max dose is, "as much as you need". 

I try to use as little as possible.


----------



## zmedic (Oct 14, 2012)

> I asked why they were performing CPR and I was told "well we hooked up the AED and it said no shock advised, start CPR... so we did." They were amazed when she miraculously came around to 0.4mg IV.
> 
> ...And this particular individual is a CPR instructor... :huh:



You are going to be seeing more and more of this as the AHA moves away from pulse checks and towards just starting CPR for lack of signs of life.


----------

