# How freely do you use Naloxone?



## Cawolf86 (Sep 30, 2011)

My question to you is how freely do you use naloxone in the treatment of patients with an acute presentation of ALOC? Mainly in a scenario where you can't rule in or rule out narcotics as the cause. I ask because I have always been one to use naloxone only  if they are altered with - known narcotic use, respiratory depression, or significant papillary findings. The new partner I am working with likes to use it on every patient who is altered with unknown etiology. Thoughts?


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## Shishkabob (Sep 30, 2011)

Depends on the situation, and while I'm opposed to cookbook medicine, I'm not opposed to giving Narcan to test if that's the cause of ALOC, even if some of the clinical findings don't match up, if all my other options come up blank.


Poly-pharm can have many different clinical findings, yet can still include opiate induced ALOC.


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## MasterIntubator (Sep 30, 2011)

I use it quite often after.... the blood glucose check, NPA use, neuro check, 12 lead, EtCO2 and anything else that may give me hints and clues.   And more times than not.... it works.

:-/


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## abckidsmom (Sep 30, 2011)

I'm not hesitant to use it if I suspect a narcotic overdose.  I don't see narcotic overdoses much anymore since I'm working out in the sticks now, but in the city it was first thought on any unresponsive, constricted-pupil person with ice in their pants.

Out here, I've had a narc OD probably just 2-3 times this year.


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## LondonMedic (Sep 30, 2011)

What are you testing?

Response to anti-narcotic drug?
Or response to pain?


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## STXmedic (Oct 1, 2011)

abckidsmom said:


> but in the city it was first thought on any unresponsive, constricted-pupil person with ice in their pants.



Lol I love all of the home remedies for heroine ODs  

If I suspect opiate/opiod/narcotic/whatever term will keep you from correcting me, overdose then I have no problems giving it. I won't just give it as an unresponsive cocktail, though.


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## systemet (Oct 1, 2011)

* Rarely, in settings where there's a clear history of isolated opiate OD, or the physical exam/circumstances strongly suggest it.  

* In very small doses to avoid intubation, but not to actually wake them up.

Different systems seem to have different answers to this situation.  It seems like places that see a lot of opiate ODs often encourage their providers to use large doses of narcan and "treat and release".  This was less common where I worked.

Narcan use has some obvious issues:

* Overaggressive use before normalising oxygenation can cause pulmonary edema.

* Removing the sedating effects of the opiate in a mixed overdose can result in worsening seizure activity.

* It complicates any further treatment that might invole using an opiate, e.g. intubation.

* Risk of acute withdrawal.

* Not to mention, most people are nicer when they're unconscious.

But I think we've discussed many of these issues before.


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## epipusher (Oct 1, 2011)

Bringing back memories of the "coma cocktail".


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## Smash (Oct 1, 2011)

Cawolf86 said:


> The new partner I am working with likes to use it on every patient who is altered with unknown etiology. Thoughts?



Your partner sounds stupid and/or lazy.


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## Fish (Oct 1, 2011)

Personally, I don't give it much as a "Lets try this out since nothing else worked, and I don't know whats wrong" type of drug.


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## the_negro_puppy (Oct 1, 2011)

I don't think its such a good idea to be giving drugs 'just in case' to 'see what happens'.

We are only permitted to use Narcan for patients with respiratory depression secondary to narcotic use, after we have attempted sufficient oxygenation and ventilation.

You should be able to rule out narcotic use by evaluating the patients appearance, scene locations, pupils, evidence of IV or oral drug use and the existence of witnesses or drugs/paraphernalia present.

Unfortunately we have set protocols here if 1.6mg of Naloxone I.M for all adult patients. Fortunately my city does not have a huge opioid scene and I have never used Naloxone in nearly 2 years.


Why would you give an ALOC patient with no respiratory depression Naloxone anyway? A patient not in opioid withdrawal is a comfortable and complaint patient.


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## ArcticKat (Oct 1, 2011)

I've been able to give Narcan for 18 years.

I've used it twice.


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## Akulahawk (Oct 1, 2011)

I quite suspect that the more "urban" the area, the more likely naloxone will be given on a more frequent basis.


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## Cawolf86 (Oct 1, 2011)

We work in a unique system - with huge rural coverage and a large urban city with a huge meth/heroin problem. He has been around a while so I am thinking it may be a throwback to an "unresponsive cocktail". I personally agree with giving naloxone based on assessment findings but I wanted to see if it was commonplace to give it to "rule out" narcotic overdoses.


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## Fish (Oct 1, 2011)

I have given it a lot, each time I was under the impression from an assesment that my patient was a Narc OD.


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## Shishkabob (Oct 1, 2011)

the_negro_puppy said:


> You should be able to rule out narcotic use by evaluating the patients appearance, scene locations, pupils, evidence of IV or oral drug use and the existence of witnesses or drugs/paraphernalia present.



That's the thing, it's not always that easy.


Hence why I mentioned poly-pharm in my other reply.


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## usafmedic45 (Oct 1, 2011)

Akulahawk said:


> I quite suspect that the more "urban" the area, the more likely naloxone will be given on a more frequent basis.



You'd be surprised.  Especially with the rise in prescription drug abuse, it's very common for some of us who have worked in rural settings to have given a lot of clinically indicated naloxone.


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## DT4EMS (Oct 2, 2011)

usafmedic45 said:


> You'd be surprised.  Especially with the rise in prescription drug abuse, it's very common for some of us who have worked in rural settings to have given a lot of clinically indicated naloxone.



Very true! I had a 22 y/o in respiratory arrest in a rural setting about 3 weeks ago. Had the classic pinpoint pupils. 

After 2mg of Narcan, and a few minutes, he was breathing on his own. We also had two deaths locally, in the same day, from Fenatnyl OD, where they mixed with apple juice to inject.


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## Aidey (Oct 2, 2011)

the_negro_puppy said:


> You should be able to rule out narcotic use by evaluating the patients appearance, scene locations, pupils, evidence of IV or oral drug use and the existence of witnesses or drugs/paraphernalia present.



I agree that it is not that easy. I recently had a teenage male who over dosed on morphine he got from a friend. Came home at 7pm, parents checked on him 5 hours later and he was nearly dead. Cyanotic, 4 respirations a minute, temp of 103 f, pupils dilated. No narcotics in the house, parents said he drank alcohol and smoked marijuana once in a while. No track marks or any other indication that he used illicit drugs. He got 2mg Narcan intranasally, and then got intubated when that hadn't done anything by the time we got him out of the house and into the amb. 

I know he was on a vent for at least 24 hours. The temp of 103 was from aspiration pneumonia, which had already set in. The kid escaped with no apparent neuro deficits aside from not remembering anything that happened the day he OD'd.


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## 18G (Oct 2, 2011)

Aidey said:


> I agree that it is not that easy. I recently had a teenage male who over dosed on morphine he got from a friend. Came home at 7pm, parents checked on him 5 hours later and he was nearly dead. Cyanotic, 4 respirations a minute, temp of 103 f, pupils dilated. No narcotics in the house, parents said he drank alcohol and smoked marijuana once in a while. No track marks or any other indication that he used illicit drugs. He got 2mg Narcan intranasally, and then got intubated when that hadn't done anything by the time we got him out of the house and into the amb.
> 
> I know he was on a vent for at least 24 hours. The temp of 103 was from aspiration pneumonia, which had already set in. The kid escaped with no apparent neuro deficits aside from not remembering anything that happened the day he OD'd.



Wow. Can we say one lucky kid?


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## Cawolf86 (Oct 2, 2011)

18G said:


> Wow. Can we say one lucky kid?



Wow - One lucky kid.


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## Aidey (Oct 2, 2011)

Yup, for sure. The doc figured that he was too hypoxic to wake up even if the narcan have any affect.


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## STXmedic (Oct 3, 2011)

Just had to give it to two patients on the same run. One was respiratory arrest, IV naloxone woke her right up; the friend was having moderate effects, but refusing to be transported, so she got an IM dose before we left. So yeah, I'd say we give it pretty freely here


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## MasterIntubator (Oct 3, 2011)

Anyone have intranasal narcan?


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## Jon (Oct 3, 2011)

MasterIntubator said:


> Anyone have intranasal narcan?


We do!

Earlier this year, I saw it take an OD from apniec to CAOx4, able to walk down the stairs to the stretcher on his own (not my doing). I like the lack of needles, and the absorption seems to be rapid enough, yet gradual enough that they don't wake up puking and fighting.


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## NomadicMedic (Oct 3, 2011)

Yep. We have IN Narcan also. I haven't used it yet. I haven't had an opiate OD in a while. 


Sent from my iPhone.


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## Aidey (Oct 3, 2011)

We 3. I've found it works great, aside from the patient mentioned above.


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## Jon (Oct 3, 2011)

Cawolf86 said:


> My question to you is how freely do you use naloxone in the treatment of patients with an acute presentation of ALOC? Mainly in a scenario where you can't rule in or rule out narcotics as the cause. I ask because I have always been one to use naloxone only  if they are altered with - known narcotic use, respiratory depression, or significant papillary findings. The new partner I am working with likes to use it on every patient who is altered with unknown etiology. Thoughts?


As for the OP's question - I take it as I see it. Sometimes I'll push it as a "why not", often I don't. It depends on the actual call. If it's "grandma won't wake up" at the SNF, if Grandma isn't covered in Fentanyl patches, I'm probably not going to push it "just because". If my patient is found down on the street at 3am Saturday with no obvious trauma and apnea? They'll get a dose on the way to the trauma center.

PA's protocols allow of up to 2mg IN/IV/IM/IO Narcan. Protocols encourage it's use for AMS tx when "evidence of opioid overdose" is present (decreased respiration, pupil constriction, track marks, and/or presence of drug paraphernalia - from PA ALS Protocol 7002). The protocols also cover use when no other EMS-treatable cause of AMS is present (not hypoxic, not hypoglycemic, etc).


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## DrParasite (Oct 4, 2011)

the_negro_puppy said:


> Why would you give an ALOC patient with no respiratory depression Naloxone anyway? A patient not in opioid withdrawal is a comfortable and complaint patient.


so I can wake up the OD patient with some naloxone and they can walk down the 3 flights of stairs to the waiting cot under their own power, or I can hurt my back carrying said OD patient down to the cot.....  quick someone grab me the Naloxone!!!


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## MasterIntubator (Oct 4, 2011)

DrParasite said:


> so I can wake up the OD patient with some naloxone and they can walk down the 3 flights of stairs to the waiting cot under their own power, or I can hurt my back carrying said OD patient down to the cot.....  quick someone grab me the Naloxone!!!




Sure would be nice.... but That is not always guaranteed... You may get 1: The runner... 2: the fighter.... 3: the vomiter... 4: the crying whiner who complains and refuses to go anywhere making your scene times 5x what they should be because now they are legally competent and now you gotta get LEO involved and make a great case to take them by force - which you may get any way...  I would love to get that compliant pt after reversal telling me how much they love me and that they will do anything I say.....  <sigh>


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## Shishkabob (Oct 4, 2011)

Or just wait a little longer till they become unconscious again because the half-life of Narcan is less than that of the drugs it reverses.


Then atleast you know it's most likely a narcotic induced loss of consciousness, and not a potentially more dangerous cause.


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## jjesusfreak01 (Oct 8, 2011)

systemet said:


> Different systems seem to have different answers to this situation.  It seems like places that see a lot of opiate ODs often encourage their providers to use large doses of narcan and "treat and release".  This was less common where I worked.





Linuss said:


> Or just wait a little longer till they become unconscious again because the half-life of Narcan is less than that of the drugs it reverses.



And this is why opiate ODs don't get to refuse in Wake County...extreme risk of secondary OD when the narcan wears off, or worse, we release them and they redose themselves because we killed their high, the narcan wears off, and then they're dead.


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## redcrossemt (Oct 13, 2011)

systemet said:


> * Rarely, in settings where there's a clear history of isolated opiate OD, or the physical exam/circumstances strongly suggest it.



Perfect post. +1


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