# Narcan and hypotension



## firemedic31075 (May 19, 2009)

Ran a call a few weeks ago for an overdose of oxycodone and Xanax. We arrived to find a 40 y/o/f lying on the floor unresponsive breathing about 6-8 times per min. Airway initially controlled with OPA and ventilated @ 12xmin. No radial pulse but good carotid, skin is cool, pale and diaphretic. pupils-pinpoint. HR- 118  EKG - b/p- 74/40 Sinus Tach. LS- clear and Equal bilat. Accucheck-108.Hx-depression . Meds- Xanax.. After admin of narcan IM pt. began gagging slightly. Pt. was RSI'd in back of unit (Etomidate and Sux). Normal Saline bolus 500ml. The lead medic begins giving narcan throughout transport, unknown to me and tells me later that we still needed to reverse the opiate induced hypotension. 

I know narcan reverses resp. depression. But will it reverse the hypotension?

I didn't think it would but I could be wrong.


----------



## Aidey (May 19, 2009)

If the patient was still hypotensive post narcan, it was probably caused by the xanax, not the hydrocodone. Narcan reverses all opiate affects, and as long as a sufficent dose of narcan was administered to counteract the hydrocodone the patient wouldn't continue to be hypotensive because of it. 

Some long acting opiates, like methadone, need very high doses of narcan repeated over time to reverse all the affect, but with hydrocodone the affects should have been reduced (if not eliminated) by the initial narcan dose, assuming it was at least a couple of MG or higher. 

Xanax on the other hand can cause a lot of side effects when taken in exess. I had a xanax OD a while back where the person took about 90mg of Xanax and ended up in the ICU for 3 days on a vent.


----------



## DV_EMT (May 20, 2009)

just asked my pharmacist about it...

It will only reverse it if it's opiate induced hypotension.

But speaking of stoopid people who decide to OD. Had a friend who told me that she took 4-5 xanax with a bunch of shots..... and wanted to use MY jacuzzi. Of course my rxn was, "no way in heck that I'd let that happen, I don't want a corpse in my jacuzzi!!"


regardless... she ended up in the ER later that night... :/

job security anyone??


----------



## Aidey (May 20, 2009)

I forgot to add that Xanax isn't an opiate. It's a benzo, which is the same family as valium and versed. Its effects can be reversed with romazicon/flumazenil (sp?), however there is a risk of inducing seizure with it, which is why you don't see it used commonly pre-hospital (or at least I haven't seen it available pre-hospital much).


----------



## maxwell (May 20, 2009)

If the lowpertension was d/t narcos, then the naloxone will reverse them.  It is important to say that narcan is NOT a vasopressor, nor does it reverse alprazolam.  For that you'll need flumazenil, also not a pressor.


----------



## Aidey (May 20, 2009)

The patient may not need a pressor once the effects of the meds have been counteracted.


----------



## Ridryder911 (May 20, 2009)

I ask why was the Narcan given IM as appearantly you were able to RSI? As well as discussed, there is still a lot of what we do not know about Narcan, too. As discussed in overdoses of Clonidine on why it has a percentage chance of working sometimes but not always (as there are theories of why it works). 

True it is for opoid products, it may be effective on other medications as well. 


R/r 911


----------



## Aidey (May 20, 2009)

Rid, do you know of any credible studies that have been done on its affects on other medications? Like you mention, there are plenty of anecdotal reports of it affecting other meds, but I'm curious about how much that has been studied.


----------



## Ridryder911 (May 20, 2009)

Sasha, asked me about Clonidine and Narcan and was able to find some info on lit research. There are some theories of why, as in related to the "blocking action" it might work upon this medication but as I described it is not a certain. 

I found two or three published reports rather easy r/t human studies and several r/t  bovine studies. 

R/r 911


----------



## AJ Hidell (May 20, 2009)

Why exactly was the patient RSI'd?


----------



## Flight-LP (May 20, 2009)

AJ Hidell said:


> Why exactly was the patient RSI'd?



im wondering the same thing...........

my other question is why narcan was given after the pt was RSI'D?


----------



## AJ Hidell (May 20, 2009)

Makes me wonder if someone didn't overmedicate with the RSI.


----------



## Aidey (May 20, 2009)

Flight LP it sounds like the medic continued to give narcan because the patient was still hypotensive (thats just a guess from the first post). 

As for the RSI, there aren't enough details here, but if someone has taken a benzo OD, and you don't have flumazenil on your ambulance, and the patient can't maintain their own airway, then RSI could be indicated depending on the local protocol. (I know in mine it would be and option).


----------



## JPINFV (May 20, 2009)

maxwell said:


> If the lowpertension was d/t narcos, then the naloxone will reverse them.  It is important to say that narcan is NOT a vasopressor, nor does it reverse alprazolam.  For that you'll need flumazenil, also not a pressor.



lowpertension?


----------



## daedalus (May 20, 2009)

AJ Hidell said:


> Why exactly was the patient RSI'd?



I am asking the same question. Plus, once the patient's tubed, if you can stabilize the BP, why even give the Narcan?


----------



## AJ Hidell (May 20, 2009)

daedalus said:


> I am asking the same question. Plus, once the patient's tubed, if you can stabilize the BP, why even give the Narcan?


Seriously.  The last thing I want is for my tubed patient to become un-gorked in the field.  But then again, I wouldn't have tubed this one in the first place.


----------



## Flight-LP (May 20, 2009)

Aidey said:


> Flight LP it sounds like the medic continued to give narcan because the patient was still hypotensive (thats just a guess from the first post).
> 
> As for the RSI, there aren't enough details here, but if someone has taken a benzo OD, and you don't have flumazenil on your ambulance, and the patient can't maintain their own airway, then RSI could be indicated depending on the local protocol. (I know in mine it would be and option).




Hate to write and run as I only have a couple of minutes, but a few points that need to be addressed..............

1. If a pt. is truly a GCS of 3, then why the need for paralytics??? Granted, the condition or neuro response can change, but if they are truly unresponsive without a gag, then just drop the ET tube. Risk vs. benefit.

2. Narcan after intubation, especially with RSI, is a horribly ignorant (or stupid if you already know better) idea. You sedate, paralyze, and provide analgesia for a reason. That reason is not to reverse it. Plus, analgesia is a must with RSI. Lets look at our options, usually Morphine or Fentanyl. What is Narcan going to do to either them?????? Hmmmmm...

3. Leave Romazicon out of this conversation. The only reason we in the pre-hospital environment should be giving this antagonist is for our own screw-ups, i.e. a Paramedic induced benzodiazepine OD. Too many people run and start slamming Romazicon with no clue as to the potential complications. Most benzos have a relatively short half life. Romazicon is overused and rarely truly needed.

Sorry, but your medic needs to revisit some basic airway education, along some recent literature and research. Hopefully, everyone learns a little something out of this.

Take care, be safe!


----------



## firemedic31075 (May 21, 2009)

> Why exactly was the patient RSI'd?



After the my partner gave 2mg of narcan IM the pt. began gagging on the OPA and continued to have a gag reflex when we go to the back of the unit so the decision was made to RSI rather than attempt to just tube her and risk vomiting and aspiration.



> I ask why was the Narcan given IM as appearantly you were able to RSI?



It was given initially on scene before we had an IV.



> once the patient's tubed, if you can stabilize the BP, why even give the Narcan?



That's what I was thinking..our protocol is Etomidate and Succs for RSI (we don't use any opiates in RSI other than a trauma situation) and versed and Vecc for longer duration, which narcan wouldn't affect, so I guess there was no harm in giving it. I myself would not have given it had I been the lead medic. I would have tried other measures to correct the b/p



> Seriously. The last thing I want is for my tubed patient to become un-gorked in the field. But then again, I wouldn't have tubed this one in the first place



Why would you not tube this pt.?? She is completely unresponsive.


Thanks for all the feedback so far.


----------



## maxwell (May 21, 2009)

Yeah yeah yeah, lowpertension = hypotension.  

I'm gonna give an amen to NOT giving naloxone to an intubated patient.  They can do it in the ED as a diagnostic if they really want to (when they can *quickly* snow 'em again with the milk of amnesia).  I am a fan of my intubated patients not moving.  

I'm not sure I would have intubated, either, frankly.  But, I wasn't there.  Hell where I'm from we make those types walk to the rig h34r:.


----------



## AJ Hidell (May 21, 2009)

firemedic31075 said:


> Why would you not tube this pt.?? She is completely unresponsive.


If she is gagging on an OPA, she is not completely unresponsive.  If she is gagging on an OPA, she doesn't need an OPA.  If she doesn't need an OPA, then she darn sure doesn't need an ETT.  Not every unconscious person needs an ET tube.  An ET tube is not simply a lazy medic's way of getting out of basic airway control.  I just don't think you'd find too many medical control physicians who would say this was justified PAI.

That is just extremely poor planning and decision making to hit someone with naloxone and then RSI them.


----------



## vquintessence (May 21, 2009)

Thank god for our pts that we don't carry flumazenil.  Frankly it's because of ignorance that much of EMS has lost it.  "Titrate to effect" is too complicated.  :glare:

God help us if we lose the security of carrying naloxene.  Those stories we hear all too often of pts getting slammed 2 mg IVP... well they get heard out of our realm.


----------



## firemedic31075 (May 21, 2009)

> If she is gagging on an OPA, she is not completely unresponsive. If she is gagging on an OPA, she doesn't need an OPA. If she doesn't need an OPA, then she darn sure doesn't need an ETT. Not every unconscious person needs an ET tube. An ET tube is not simply a lazy medic's way of getting out of basic airway control. I just don't think you'd find too many medical control physicians who would say this was justified PAI.



I'm sorry but this doesn't make sense to me. You say if she's gagging on an OPA she doesn't need to be intubated via RSI. I though that was the point of RSI, the ability to  intubate someone that has a gag reflex. She is unresponsive and had vomited and aspirated a bit before we got there not to mention the slow resp. rate and poor tidal volume. If I walked into the ER with a pt. that has a GCS of 3 and vomit all over their face and didnt have them tubed, I think the first thing they would do is chew me out then tube the pt.

those are my thoughts anyways...Im trying to understand how not intubating this person would be beneficial...


----------



## Aliakey (May 21, 2009)

I'm not trying to start any wars, just kinda confused.  With the first post, you indicated that the lungs were clear bilaterally ("LS- clear and Equal bilat.").  Your second post states, "After the my partner gave 2mg of narcan IM the pt. began gagging on the OPA and continued to have a gag reflex when we go to the back of the unit so the decision was made to RSI rather than attempt to just tube her and risk vomiting and aspiration".  And now I read in your last post, "She is unresponsive and had vomited and aspirated a bit before we got there...".   ?????  Did she or did she not vomit PTA?

Anyway, for what I've learned and experienced, and of course subject to all sorts of scrutiny :

1.  Can the patient protect her own airway?

Gag reflex in itself is not the best indicator of whether a patient can protect her airway or not.  A better indicator is a swallow reflex, which is a more complex reflex requiring the patient to sense and initiate an effort to move secretions down the esophagus.  Could she swallow?   Did anyone take a few seconds to watch?   I have seen patients with very low GCS scores still preserve an ability to swallow, particularly those who have overdosed on drugs or alcohol.  GCS alone is not a good indicator.  

I may have to purchase this paper just because it'll bug me down the road if I don't, but the abstract itself is enlightening:  Decreased Glasgow Coma Scale Score Does Not Mandate Endotracheal Intubation in the Emergency Department 

Anyway, with the contradicting information presented about this patient so far, this question cannot be answered.


2.  Is the patient being oxygenated adequately? 

Breathing in itself is not an indication that the airway is protected or that adequate oxygenation is occurring.   If the patient has a swallow reflex and can be maintained with her head elevated, can a less invasive means be used instead of an ET tube?  How about just long enough to see if a couple of rounds of Narcan might work (seeing that one round apparently improved the patient's responsiveness)?


3.  What caused this patient's demise?  Personally, I'm on the same boat with the others: Narcan first for the OD scenerio... pharmaceutically-assisted intubation later, if needed.  If the patient had already aspirated as suggested in the third post, then then damage has already began.  You can tube the patient, deep suction what aspirate you can, push the naloxone, and watch her wake up and fight you to pull the garden hose out of her throat as the Versed quietly wears off when you just turned around "for a second" and not watched her.  You'll never get all of the aspirate out with the deep suction anyway, and you risk the tracheal damage from his self-extubation.  And on certain patients, they may never be able to breath on their own again once tubed.  It's a sad scenerio I've seen happen.

Or, IMHO, better to hope that you can wake the appropriately-positioned patient with the Narcan first and let her cough the crud out of her lungs, on her own.  Again though, her ability to swallow is in question, and not something I see being answered in the three contradictory posts.

Just throwing out ideas.


----------



## firemedic31075 (May 21, 2009)

sorry for the confusion. When we first got on scene I noticed some vomit on the floor and on her face, when I opened the airway there was still some in there which I suctioned (it looked to me like she may have aspirated a bit).  and then put in an OPA (at this time she has no gag reflex) and began ventilation. I listened to lung sounds which were clear and equal. Narcan was given and she began gagging, but no increase in LOC. We decided to intubate but the pt now had a gag reflex so we did not want to risk (vomiting and aspiration) trying to tube her without paralytics. 

does that clear things up? or just make it worse? haha


----------



## Flight-LP (May 21, 2009)

firemedic31075 said:


> That's what I was thinking..our protocol is Etomidate and Succs for RSI (we don't use any opiates in RSI other than a trauma situation) and versed and Vecc for longer duration, which narcan wouldn't affect, so I guess there was no harm in giving it. I myself would not have given it had I been the lead medic. I would have tried other measures to correct the b/p.



No analgesia for RSI?!?!?!?!?!?!? 

That's just cruel................

I agree with your last statement, Narcan would have been the last thing on my mind, especially after your pt. bought an ET tube.


----------



## boingo (May 22, 2009)

AJ Hidell said:


> If she is gagging on an OPA, she is not completely unresponsive.  If she is gagging on an OPA, she doesn't need an OPA.  If she doesn't need an OPA, then she darn sure doesn't need an ETT.  Not every unconscious person needs an ET tube.  An ET tube is not simply a lazy medic's way of getting out of basic airway control.  I just don't think you'd find too many medical control physicians who would say this was justified PAI.
> 
> That is just extremely poor planning and decision making to hit someone with naloxone and then RSI them.



Very well put.


----------



## boingo (May 22, 2009)

I think the problem people are having, at least I'm having is if you find someone that you feel has overdosed on an opiate, and your plan is to correct their respiratory status by reversing it with narcan, fine, but you don't go down that road, and now, as the narcan is doing what it is supposed to (increasing respiratory rate and LOC) and the patients gag reflex returns, the next step should be to remove the OPA causing the pt to gag, not to do a 180 and RSI them.  If the game plan is to secure the airway, then reversing the effect of the opiate is a bad idea, whether you include an anelgesic in your PAI/RSI algorithm or not.


----------



## smurfe (May 25, 2009)

I have gave Narcan way more times for hypotention than respiratory depression. These are the two reasons you give narcan (respiratory depression and hypotention) and it shouldn't be given just because a narcotic is on board. Flumazenil could of been given to the patient for the Benzo but i don't like to give it as a few times I have the patient had a seizure when they came around and then I was hosed treating that.


----------

