# Should we use Narcan on all CPR calls?



## RobertAlfanoNJEMT (Sep 22, 2016)

I went on a call last week, 37 y/o male appeared healthy, CPR in progress died at the Hospital.. in hindsight I realize how it is strange for him to be in this situation at such a young age and could have been due to an overdose or bad mix of meds.. Should we give every CPR/non-breathing pt narcan? We don't know there history or how they got in that situation, and administering it cannot do any harm to them. Let me know what you think!


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## DesertMedic66 (Sep 22, 2016)

No.


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## Flying (Sep 22, 2016)

With this rationale we might as well as give Narcan for AMS, drunkeness, and drowsiness.


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## DesertMedic66 (Sep 22, 2016)

Narcan is not recommended in the treatment of cardiac arrests. Patients who overdosed will go into cardiac arrest due to respiratory arrest/depression. Giving Narcan isn't going to do anything for this patient because because the patient does not have a pulse. Since there is no pulse that means there is no respiratory drive. 

If you have a respiratory arrest patient who still has a pulse then Narcan may be indicated based on assessment findings and scene surroundings.


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## RobertAlfanoNJEMT (Sep 22, 2016)

I knew when I said "it can't hurt them to give it" that that would start some conversation.. I do not like to go by that logic often but in this case I kind of am for it


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## DesertMedic66 (Sep 22, 2016)

What in this case makes you think it is reasonable?

Giving Narcan to a full arrest isn't going to suddenly bring them back to life. There is a huge difference between using Narcan when the patient has a pulse and when the patient doesn't. 

Also, Narcan does have side effects


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## RobertAlfanoNJEMT (Sep 22, 2016)

DesertMedic66 said:


> Narcan is not recommended in the treatment of cardiac arrests. Patients who overdosed will go into cardiac arrest due to respiratory arrest/depression. Giving Narcan isn't going to do anything for this patient because because the patient does not have a pulse. Since there is no pulse that means there is no respiratory drive.
> 
> If you have a respiratory arrest patient who still has a pulse then Narcan may be indicated based on assessment findings and scene surroundings.


What about in the situation where it isn't cardiac arrest but an irregular heart rythem such as sinus tach or v tach? That is what I believe had happened with my patient since the AED indicated a shock 5 times before I had cleared the scene


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## RobertAlfanoNJEMT (Sep 22, 2016)

DesertMedic66 said:


> What in this case makes you think it is reasonable?
> 
> Giving Narcan to a full arrest isn't going to suddenly bring them back to life. There is a huge difference between using Narcan when the patient has a pulse and when the patient doesn't.
> 
> Also, Narcan does have side effects


I was always told that there are essentially no side effects to Narcan other than those of opioid withdrawal.. can you tell me what these side effects are? I'm not here to challenge anyone's thoughts or knowledge, I am genuinely trying to get more information and insight on a topic I do not know all that much about


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## DesertMedic66 (Sep 22, 2016)

RobertAlfanoNJEMT said:


> What about in the situation where it isn't cardiac arrest but an irregular heart rythem such as sinus tach or v tach? That is what I believe had happened with my patient since the AED indicated a shock 5 times before I had cleared the scene


AEDs do not shock sinus tach. The only 2 rhythms that AEDs shock are V-tach (with no pulses that should be checked by the provider) and V-fib. Both V-Fib and pulseless V-tach are cardiac arrest rhythms


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## DesertMedic66 (Sep 22, 2016)

RobertAlfanoNJEMT said:


> I was always told that there are essentially no side effects to Narcan other than those of opioid withdrawal.. can you tell me what these side effects are? I'm not here to challenge anyone's thoughts or knowledge, I am genuinely trying to get more information and insight on a topic I do not know all that much about


http://www.rxlist.com/script/main/mobileart-rx.asp?drug=narcan&monotype=rx-desc&monopage=0


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## RobertAlfanoNJEMT (Sep 22, 2016)

DesertMedic66 said:


> AEDs do not shock sinus tach. The only 2 rhythms that AEDs shock are V-tach (with no pulses that should be checked by the provider) and V-fib. Both V-Fib and pulseless V-tach are cardiac arrest rhythms


Thanks for that.. I think the issue with making equipment like the AED so user friendly is that it does not require the provider to learn the back ground info


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## NomadicMedic (Sep 22, 2016)

RobertAlfanoNJEMT said:


> Thanks for that.. I think the issue with making equipment like the AED so user friendly is that it does not require the provider to learn the back ground info



If you're using an AED, you don’t need any background info. In the case of a cardiac arrest, you should apply the pads, push the analyze button and then hit the lightning bolt button if the box says "shock advised". If you need more background than that, become a paramedic.


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## DesertMedic66 (Sep 22, 2016)

RobertAlfanoNJEMT said:


> Thanks for that.. I think the issue with making equipment like the AED so user friendly is that it does not require the provider to learn the back ground info


AEDs are intended more for the public to use. Joe Q Citizen is working out at the guy and another friendly gym rat goes down. Mr. Citizen grabs the AED and puts in on and does exactly what the machine tells him to do. No real training is needed. As long as you can look at a picture and follow very basic steps you can use the AED.


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## EpiEMS (Sep 22, 2016)

RobertAlfanoNJEMT said:


> I went on a call last week, 37 y/o male appeared healthy, CPR in progress died at the Hospital.. in hindsight I realize how it is strange for him to be in this situation at such a young age and could have been due to an overdose or bad mix of meds.. Should we give every CPR/non-breathing pt narcan? We don't know there history or how they got in that situation, and administering it cannot do any harm to them. Let me know what you think!



If you're doing CPR, they need two (let's call it two and a half) things: compressions (and ventilation, eventually) and defibrillation. Naloxone, especially IM or IN, is probably not going to do very much - if anything. Firstly, it's going to distract you from more important things - compressions (and ventilations - which are what opioid overdose patients *really* need, if they need anything at all) and defibrillation. Secondly, it may not even circulate enough to do what it needs to do. Third, think about what naloxone does ("Naloxone is a potent opioid receptor antagonist in the brain, spinal cord, and gastrointestinal system") in the context of *cardiac * arrest. Not to mention, even if you get pulses back, there are downsides to naloxone administration in a peri-arrest state.

Short answer: Naloxone is indicated for severe respiratory distress related to or plausibly related to opioid overdose. It's not indicated for cardiac arrest.




RobertAlfanoNJEMT said:


> I knew when I said "it can't hurt them to give it" that that would start some conversation.. I do not like to go by that logic often but in this case I kind of am for it



It can hurt them - they don't  need naloxone, they need compressions and defibrillation.


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## medichopeful (Sep 22, 2016)

RobertAlfanoNJEMT said:


> What about in the situation where it isn't cardiac arrest but an irregular heart rythem such as sinus tach or v tach? That is what I believe had happened with my patient since the AED indicated a shock 5 times before I had cleared the scene



If your AED is recommending defibrillation for a patient in sinus tach it might need recalibration. 

If your patient is in sinus tach because they have a decreased respiratory drive due to an opiate overdose, by all means administer narcan (carefully).  If you believe that the v-tach (with a pulse) is caused by hypoxia related to an opiate overdose, fix the hypoxia then give the narcan when they're not in v-tach anymore.


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## medichopeful (Sep 22, 2016)

RobertAlfanoNJEMT said:


> I was always told that there are essentially no side effects to Narcan other than those of opioid withdrawal.. can you tell me what these side effects are? I'm not here to challenge anyone's thoughts or knowledge, I am genuinely trying to get more information and insight on a topic I do not know all that much about



Good for you man!  Not everybody has the desire to learn (sadly), so it's good that you're asking questions.

Some side effects of narcan:
"Withdrawal reaction precipitated, abrupt reversal of narcotic depression may result in nausea, vomiting, sweating, tachycardia, increased blood pressure and tremulousness, cardiac arrest, ventricular fibrillation, dyspnea, pulmonary edema, abdominal cramps, diarrhea" (http://reference.medscape.com/drug/narcan-naloxone-evzio-343741#4)

Hope this helps!


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## RobertAlfanoNJEMT (Sep 22, 2016)

medichopeful said:


> Good for you man!  Not everybody has the desire to learn (sadly), so it's good that you're asking questions.
> 
> Some side effects of narcan:
> "Withdrawal reaction precipitated, abrupt reversal of narcotic depression may result in nausea, vomiting, sweating, tachycardia, increased blood pressure and tremulousness, cardiac arrest, ventricular fibrillation, dyspnea, pulmonary edema, abdominal cramps, diarrhea" (http://reference.medscape.com/drug/narcan-naloxone-evzio-343741#4)
> ...


Aren't those all side effects of opioid withdrawal? I realize they are serious side effects but it's kind of the risk you take when you shoot heroin into your arm right?


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## VentMonkey (Sep 22, 2016)

DEmedic said:


> If you're using an AED, you don’t need any background info. In the case of a cardiac arrest, you should apply the pads, push the analyze button and then hit the lightning bolt button if the box says "shock advised". If you need more background than that, become a paramedic.


I have not LOL-d this hard in a while.

Op, if you're that interested in a paramedics drug kit, and what all they do and when to (or not to) use, as stated above...become a paramedic.


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## StCEMT (Sep 22, 2016)

EpiEMS pretty much summed up what I was gonna say. Sure, you could think about it, but there is a nice list of other much more important things that need to be done first before even giving narcan.


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## VentMonkey (Sep 22, 2016)

RobertAlfanoNJEMT said:


> Aren't those all side effects of opioid withdrawal? I realize they are serious side effects but it's kind of the risk you take when you shoot heroin into your arm right?


Op, furthermore understand, I'm not laughing at you. You do seem genuinely curious. That is commendable.

Seriously, get your paramedic, chances are you'll do well. And yes, those are also common side effects for opiate-dependant withdrawals, but honestly you take too much of anything and it will make you sick enough to include the vast majority of the listed side effects.

Narcan is not a drug one should give anymore as they used to say 10-20 years ago when cardiac arrests were very much a "kitchen sink" approach. Prehospital medicine is ever changing, as is most, if not, all medicine. 

The more prudent prehospital providers pride themselves on a strong clinically based approach, judging by your genuine curiousity, this makes for the solid foundation of a strong paramedic to be.


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## ERDoc (Sep 23, 2016)

It's a little old but some food for thought:

https://www.ncbi.nlm.nih.gov/pubmed/19913979


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## VentMonkey (Sep 23, 2016)

ERDoc said:


> It's a little old but some food for thought:
> 
> https://www.ncbi.nlm.nih.gov/pubmed/19913979


With that said, is this something you still advocate for, and/ or implement in this specific group of cardiac arrest patients, Doc?

I now seem to be the one who's genuinely curious.


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## DesertMedic66 (Sep 23, 2016)

I saw the study a little while ago. So 15 out of 36 patients had EKG changes after Narcan. 47% of the 15 (so 7) had changed immediately after the Narcan was given


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## StCEMT (Sep 23, 2016)

Hmm....actually kinda curious myself now


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## kev54 (Sep 23, 2016)

Critmedic had a podcast with this exact study here is his take. https://www.critmedic.com/podcasts/episode-14-when-narcan-nar-cant/

Keep in mind all were pronounced except one which doesn't sound promising and some of them died in the hospital setting. There were two where there was no follow up. Justify the cost benefit analysis? Can we make a definitive conclusion with this limited data? More studies may be needed before a quality answer is reached.


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## Bullets (Sep 23, 2016)

I think we should just give every unconscious patient an amp of dextrose, 0.2mg flumazenil, 2mg narcan and 100mg of thiamine

There was a time, not to long ago, that we dealt with overdoses with a BVM and people woke up on the way to the ER. If the patient is in arrest, good ventilation will counter the opiod


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## NomadicMedic (Sep 23, 2016)

Bullets said:


> dextrose, 0.2mg flumazenil, 2mg narcan and 100mg of thiamine



Everybody gets the coma cocktail!


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## VentMonkey (Sep 23, 2016)

DEmedic said:


> Everybody gets the coma cocktail!


Let's not forget the Calcium Chlordie and Bicarb in spite of checking downtimes, and/ or serious suspicious for hyperkalemia in said cardiac arrest patients (RF patients anyone?)


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## NomadicMedic (Sep 23, 2016)

Why not chuck a gram of mag in there too?


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## VentMonkey (Sep 23, 2016)

DEmedic said:


> Why not chuck a gram of mag in there too?


I may have to dust off the ol' Biophone for that one. Too much thinking makes my head hurt.


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## EpiEMS (Sep 23, 2016)

DEmedic said:


> Everybody gets the coma cocktail!



That's just Sunday brunch, my good sir!

In all seriousness, naloxone for everyone is the kind of thing that gets EMS treated as the red-headed stepchild at the healthcare table.


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## ERDoc (Sep 23, 2016)

I think the idea is that more studies need to be done and the meds have to be given to the correct pt population.  Giving narcan to a 99y/o cardiac arrest would not be the correct pt.  The 20 or 30 something with known access to opiates, maybe we would see a difference if we could get a big enough sample size.  My personal sample size is low and all were given narcan prior to arrival in the ER but I have not had any survivors.  However, anecdote doesn't equal evidence.


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## VentMonkey (Sep 23, 2016)

ERDoc said:


> I think the idea is that more studies need to be done and the meds have to be given to the correct pt population.  Giving narcan to a 99y/o cardiac arrest would not be the correct pt.  The 20 or 30 something with known access to opiates, maybe we would see a difference if we could get a big enough sample size.  My personal sample size is low and all were given narcan prior to arrival in the ER but I have not had any survivors.  However, anecdote doesn't equal evidence.


Awesome insight, thanks Doc!


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## NomadicMedic (Sep 23, 2016)

Hmmm... How did I miss this before? The AHA is saying we (including lay responders and BLS) should give Narcan, to anyone suspected of an opiate OD in cardiac arrest. 

"Experience with treatment of patients with known or suspected opioid overdose has demonstrated that naloxone can be administered with apparent safety and effectiveness in the first aid and BLS settings. For this reason, naloxone administration by lay rescuers and HCPs is now recommended, and simplified training is being offered. In addition, a new algorithm for management of unresponsive victims with suspected opioid overdose is provided."







Highlights of the 2015 American Heart Association Guideline Updates for CPR and ECC at https://eccguidelines.heart.org/wp-...10/2015-AHA-Guidelines-Highlights-English.pdf.


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## EpiEMS (Sep 23, 2016)

DEmedic said:


> The AHA is saying we (including lay responders and BLS) should give Narcan, to anyone suspected of an opiate OD in cardiac arrest.


They specified that this is for patients with a pulse, but abnormal breathing, I believe.


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## NomadicMedic (Sep 23, 2016)

EpiEMS said:


> They specified that this is for patients with a pulse, but abnormal breathing, I believe.



Actually... It's for a suspected opiate arrest, with the hedge being that the first responder may not beable to differentatte between respiratory arrest and a full cardiac arrest.

*Cardiac Arrest in Patients With Known or Suspected Opioid Overdose* 2015 (New): Patients with no definite pulse may be in cardiac arrest or may have an undetected weak or slow pulse. These patients should be managed as cardiac arrest patients. Standard resuscitative measures should take priority over naloxone administration, with a focus on high-quality CPR (compressions plus ventilation). It may be reasonable to administer IM or IN naloxone based on the possibility that the patient is in respiratory arrest, not in cardiac arrest. Responders should not delay access to more-advanced medical services while awaiting the patient’s response to naloxone or other interventions.

This is a better first responder algorithm.


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## EpiEMS (Sep 23, 2016)

DEmedic said:


> Actually... It's for a suspected opiate arrest, with the hedge being that the first responder may not beable to differentatte between respiratory arrest and a full cardiac arrest.
> View attachment 3010



Given the caveat (and the prioritization of CPR over naloxone administration), I suppose that makes sense.


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## cprted (Sep 24, 2016)

Without delving into the Naloxone in Cardiac Arrest discussion, what makes you think this person is in arrest secondary to a drug overdose?  Just because they're on the younger side?  Was there drug paraphernalia at the scene? Do they have a history of drug abuse? Were there empty pill bottles? Tract marks?

Could they be a Brugada Syndrome? PE? Undiagnosed hypertrophic cardiomyopathy? Tension Pneumo? Hemorrhagic CVA?


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## rescue1 (Oct 20, 2016)

cprted said:


> Without delving into the Naloxone in Cardiac Arrest discussion, what makes you think this person is in arrest secondary to a drug overdose?  Just because they're on the younger side?  Was there drug paraphernalia at the scene? Do they have a history of drug abuse? Were there empty pill bottles? Tract marks?
> 
> Could they be a Brugada Syndrome? PE? Undiagnosed hypertrophic cardiomyopathy? Tension Pneumo? Hemorrhagic CVA?



Where I worked, most younger arrests were secondary to drug overdose, especially opiates. But short of obvious signs there's really no way to know, especially since many chronic drug abusers will have other health problems.


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## phideux (Oct 21, 2016)

EpiEMS said:


> They specified that this is for patients with a pulse, but abnormal breathing, I believe.




The first flow-chart Demedic put up says this, administer Narcan per protocol, in pt with a pulse and abnormal resps. The second one he put up is a different one showing the flow-chart for a cardiac arrest with suspicion of Opiate OD.


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## NPO (Oct 28, 2016)

If the cardiac arrest is due to opiate overdose, ventilation and oxygen is a much better fix than narcan. 

Sent from my SM-G935T using Tapatalk


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## EpiEMS (Oct 29, 2016)

RogueMedic, of blog fame, has a good post about this very issue.


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## Carlos Danger (Oct 29, 2016)

NPO said:


> If the cardiac arrest is due to opiate overdose, ventilation and oxygen is a much better fix than narcan.
> 
> Sent from my SM-G935T using Tapatalk



Not necessarily true. Opioids affect more than respiratory drive. A large overdose is effectively a chemical sympathectomy which ventilation will do nothing to treat.


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## EpiEMS (Nov 3, 2016)

Remi said:


> Not necessarily true. Opioids affect more than respiratory drive. A large overdose is effectively a chemical sympathectomy which ventilation will do nothing to treat.



At the BLS level, though, isn't the single most important (temporizing) intervention positive pressure ventilation?


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## Carlos Danger (Nov 3, 2016)

EpiEMS said:


> At the BLS level, though, isn't the single most important (temporizing) intervention positive pressure ventilation?



Well if you don't have narcan available, then sure - you just do the best you can do. Which at the BLS level, means opening the airway and providing oxygen and PPV as needed.

But if the patient has arrested, then we've moved beyond the point where respiratory depression is the only problem we have to deal with. You still focus on the basics of CPR, of course - defib when indicated, chest compressions, ventilation. After that though, you start to think about reversible causes. That's where narcan comes in.

If the arrest is secondary to an opioid OD, then it's _likely_ that the arrest was caused by hypoxemia, and you probably don't need narcan in order to resuscitate. However, if it was a very large OD, the sympatholytic effects of opioids could have played a role in the arrest, and could also play a role in making resuscitation more difficult. This is where narcan could potentially be beneficial.

Even if you aren't worried about the sympatholytic effects of the opioids, you still want the patient to breath on their own once you get pulses back, right? That's the simplest reason to use it.


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## EpiEMS (Nov 4, 2016)

Remi said:


> Even if you aren't worried about the sympatholytic effects of the opioids, you still want the patient to breath on their own once you get pulses back, right? That's the simplest reason to use it.



Absolutely - I just don't have great means of titrating to respiration but not full arousal, if you will, (and titrating is technically contrary to my protocols) with my IN naloxone.


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## RobertAlfanoNJEMT (Jan 14, 2017)

Haven't been on in a while, but just read all of the messages. Good conversation, I think everyone learned something.


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## NomadicMedic (Jan 14, 2017)

RobertAlfanoNJEMT said:


> Haven't been on in a while, but just read all of the messages. Good conversation, I think everyone learned something.



Did you learn that narcan is in no way indicated for every cardiac arrest?


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## RobertAlfanoNJEMT (Jan 14, 2017)

DEmedic said:


> Did you learn that narcan is in no way indicated for every cardiac arrest?


No, I learned that administering it to a cardiac arrest patient with a suspected opioid overdose would be benificial.


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## VentMonkey (Jan 14, 2017)




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## StCEMT (Jan 14, 2017)

RobertAlfanoNJEMT said:


> No, I learned that administering it to a cardiac arrest patient with a suspected opioid overdose would be benificial.


You....You realize you said the exact same thing worded differently?


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## medicdan (Jan 15, 2017)

I'll quote a favorite medical director, "An overdose is not acute hypo-naloxemia, it is hypoventilation/hypoxia". Focus on treating the breathing. If no pulse is present follow the "C-A-Bs", focus on circulation. 

Sent from my Pixel using Tapatalk


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## VentMonkey (Feb 1, 2017)

Anyone ever get those Jems issues clumped together seemingly close, like before you've even gotten a chance to peruse the previous issue(s)? Anyhow, here's a not-so-bad piece applicable to the "Let's Narcan The World" folks. 

http://www.jems.com/articles/print/...owing-naloxone-at-every-overdose-patient.html


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## Ginger care (Mar 2, 2017)

DesertMedic66 said:


> What in this case makes you think it is reasonable?
> 
> Giving Narcan to a full arrest isn't going to suddenly bring them back to life. There is a huge difference between using Narcan when the patient has a pulse and when the patient doesn't.
> 
> Also, Narcan does have side effects


Yeah one of the biggest is now everyone and there idiot mother thinks we should sell it over the counter, giving drug dealers the brilliant idea to sell it with the drugs to idiot kids who think that now heroin isn't dangerous and end up overdosing anyway like you guessed it....idiots.


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## NomadicMedic (Mar 2, 2017)

Ginger care said:


> Yeah one of the biggest is now everyone and there idiot mother thinks we should sell it over the counter, giving drug dealers the brilliant idea to sell it with the drugs to idiot kids who think that now heroin isn't dangerous and end up overdosing anyway like you guessed it....idiots.



That is a shortsighted view. If your son or daughter had an addiction issue, wouldn't you think it would be prudent to have Narcan in the house?  It absolutely should be available over the counter. And you certainly shouldn't judge opiate addicts simply because you don't like them or you don't like what they do.


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## VentMonkey (Mar 2, 2017)

Could not agree with @NomadicMedic more. Ginger care, if this is how you view potential patients I feel bad for _you_. 

Your post indicates lack of maturity, pointless judgment, and apathy. This in turn makes for the lethal triad on a quick road to burn out, if in fact, you're not already there.


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## StCEMT (Mar 2, 2017)

Why shouldn't it be? It's more beneficial to have it for very obvious reasons. We are literally going to do the same damn thing once we get there and I know I personally like stuff done for me already. I might not agree with their career choice, but if drug dealers are selling it with their stuff then good for them. Hell, that's just smart business if anything.


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## Ginger care (Mar 2, 2017)

NomadicMedic said:


> That is a shortsighted view. If your son or daughter had an addiction issue, wouldn't you think it would be prudent to have Narcan in the house?  It absolutely should be available over the counter. And you certainly shouldn't judge opiate addicts simply because you don't like them or you don't like what they do.


Never did I judge addicts so please don't twist my words to build your soapbox. Also I stand by my point that doing heroin is idiotic, not judging, dont think they are less human or scum of the earth. Im not going to withhold any level of care whatsoever, but how is it not idiotic....seriously if you think heroin is a good idea you are an idiot. Also I have kids, love them, but all kids are idiots at some point and if you have kids you know that. And last I checked heroin isn't really a "sorry I backed into the garage door" teachable moment, overdosing tends to be a little more permanent.  Children are literally dying everyday from it and I don't see how telling them we can instantly fix them with a atomizer or injection is really the message we should send. If you paid attention I'm judging the DRUG DEALERS for taking advantage of something created to help people that is now being used as an aid to spread more poison by making it seem like it's without consequence. And it's not that I think you are stupid or naive, but I think its awfully shortsighted of YOU to think handing out this "miracle  drug" like pez hasn't had equally negative impacts. But I get it, it's like pro life vs pro choice or thin crust vs deep dish everyone has there opinion and you sir or ma'am are certainly entitled to your's.


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## Ginger care (Mar 2, 2017)

And for the record I really don't care what people are doing in there free time, do drugs don't do drugs it's your life. I'm saying not looking at it from both sides is a little reckless.


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## Carlos Danger (Mar 2, 2017)

Ginger care said:


> Never did I judge addicts so please don't twist my words to build your soapbox. Also I stand by my point that doing heroin is idiotic, not judging, dont think they are less human or scum of the earth. Im not going to withhold any level of care whatsoever, but how is it not idiotic....seriously if you think heroin is a good idea you are an idiot. Also I have kids, love them, but all kids are idiots at some point and if you have kids you know that. And last I checked heroin isn't really a "sorry I backed into the garage door" teachable moment, overdosing tends to be a little more permanent.  *Children are literally dying everyday from it and I don't see how telling them we can instantly fix them with a atomizer or injection is really the message we should send.* If you paid attention I'm judging the DRUG DEALERS for taking advantage of something created to help people that is now being used as an aid to spread more poison by making it seem like it's without consequence. And it's not that I think you are stupid or naive, but I think its awfully shortsighted of YOU to think handing out this "miracle  drug" like pez hasn't had equally negative impacts. But I get it, it's like pro life vs pro choice or thin crust vs deep dish everyone has there opinion and you sir or ma'am are certainly entitled to your's.



You have got to be kidding me.

Following your (lack of) logic, EMS shouldn't even respond to calls for drug overdoses. After all, what kind of message are we sending when we swoop in and attempt to save the life of someone who made such a foolish decision? We'll just encourage more heroin abuse.

While we are at it, let's stop responding to MVC's because let's face it, we probably encourage reckless driving by saving people from the consequences of their bad decisions.

Next we'll refuse treatment to lung cancer patients who have a history of smoking.


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## Ginger care (Mar 2, 2017)

Oh good lord, did my wife put you up to this......listen I don't care what the problem is, I never once said it has any indication of my treatment for the patient. That's something you all assumed just because I'm not totally Gung hoe for Narcan in vending machines. For people who seem overly concerned about me judging you guys are doing nothing but judging. But yes you moron reckless driving, smoking, heroin, chainsaw juggling, cliff diving and going to slipknot concerts are idiotic things to do. However I never once said I haven't done idiotic things. Including alot from that list mentioned above. I don't think it's a bad drug I love being able to use it, makes those runs way more successful in turn making me remember why I love doing this job and feeling great about being able to help someone on need. But thinking that there couldn't possibly be any bad side to _untrained _and _uneducated _people having it can be reckless.


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## Carlos Danger (Mar 2, 2017)

Ginger care said:


> Oh good lord, did my wife put you up to this......listen I don't care what the problem is, I never once said it has any indication of my treatment for the patient. That's something you all assumed just because I'm not totally Gung hoe for Narcan in vending machines. For people who seem overly concerned about me judging you guys are doing nothing but judging. But yes you moron reckless driving, smoking, heroin, chainsaw juggling, cliff diving and going to slipknot concerts are idiotic things to do. However I never once said I haven't done idiotic things. Including alot from that list mentioned above. I don't think it's a bad drug I love being able to use it, makes those runs way more successful in turn making me remember why I love doing this job and feeling great about being able to help someone on need. But thinking that there couldn't possibly be any bad side to _untrained _and _uneducated _people having it can be reckless.



Calling me a moron doesn't make your arguments any more cogent.

Now you are changing your argument from the moral hazards of narcan to the safety of laypersons using it. 

Try reading some research on the topic and maybe then you can discuss it intelligently.


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## StCEMT (Mar 2, 2017)

Ginger care said:


> But thinking that there couldn't possibly be any bad side to _untrained _and _uneducated _people having it can be reckless.


Care to elaborate?


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## Ginger care (Mar 2, 2017)

Why can't it be both? Is not thinking about the consequences from all sides the very recklessness I was speaking of. How dare I have multiple points about something I belive, quick set me on fire and throw me in the river. The moral is secondary to the saftey of the issue. Ever heard of something called a "pharm party". The idea is all these kids show up and bring as many different script pills as they can, find and dump them into a giant bowl. They then decide some sort of order and proceed to all take a big handful at a time, I know you're thinking that's something idiots would do, and you'd be right. Except they don't see it that way. Because now the CVS around the corner sells Narcan, so they can just take that and be fine. Probably thinking "well that's only good for opiates and who knows what all they are taking". But see they don't know that, these are the same kids who think that handfuls of unknown contradicting drugs are a good way to kick back. You think they are going to listen past "a drug that can save you from dying when you are overdosing" enough to know exactly what it does and how it works everytime. And even if it was only opiates, if you don't know the dose how can you know if the amount of narcotics won't outlast the Narcan, and they think there better so no one tells the parents because who wants to get yelled at, and then they die because they don't know what they're doing. Because even aspirin while over the counter isn't idiot proof. I know it seems crazy but the sad reality is it's really not that far out there. If I have it and am allowed to use it I'm going to. But for you to assume that I'm a bad clinician or a bad person just because I don't have a bleeding heart for heroin addicts is wrong. I would never bring my personal opinions on a run, thought it was still OK to have them just like the rest of you. If I was in here talking about how I think giving someone with tension pneumo a CPAP is a good idea I would understand you jumping up my *** about it because its universally a terrible idea that would kill someone, but this is ridiculous.


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## VentMonkey (Mar 2, 2017)

@Ginger care I have zero idea where you're going with your rants, but what about this:

Exactly how well "trained", or "educated" is that cop or EMR who blindly pushes Narcan on a "suspected OD" regardless of the suspected drug of choice? Is this any better than John Q. Opium buying Narcan for their nightly "fix"? 

Same first responders show up to a polypharm party (yes, we all know what that is) and nasal spray any, and every suspected unconscious person at said party, is this any better? Yes? No? Why, or why not?


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## StCEMT (Mar 2, 2017)

It probably would be a false sense of security for some. If they are gonna die anyway, then what's it matter whether or not they have the Narcan?


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## Ginger care (Mar 2, 2017)

VentMonkey said:


> I get what your saying, it's a fair point and I mean that I'm not trying to be a ****. But I guess I would rather have a emr or a cop that has had even minimal training but specific to stressful situations do it than a 16 year old kid freaking out because he thinks I'm dying and can't think clearly. Also it can take up to 3 minutes to counteract the narcs, so does that kid getting a straight D minus average who couldn't care less about life know rescue breathing? Sorry I'm done ranting, I just think when people say that it has no downside it's not being thought through enough.


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## Ginger care (Mar 2, 2017)

Wow I ****ed that up bad, alright I'm done.


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## CALEMT (Mar 3, 2017)

Ginger care said:


> Wow I ****ed that up bad, alright I'm done.



Do you even know clinically why narcan would be used? Or what like the 1 major indication is to administer narcan is?


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## DrParasite (Mar 3, 2017)

VentMonkey said:


> @Ginger care I have zero idea where you're going with your rants, but what about this:
> 
> Exactly how well "trained", or "educated" is that cop or EMR who blindly pushes Narcan on a "suspected OD" regardless of the suspected drug of choice? Is this any better than John Q. Opium buying Narcan for their nightly "fix"?


what are the downsides to this?  No wait, let me clarrify: other than the cost of the medication, or the false safety net, what will the negative patient outcome be for the patient?  Or are there any negative side affects, other than it won't work?



VentMonkey said:


> Same first responders show up to a polypharm party (yes, we all know what that is) and nasal spray any, and every suspected unconscious person at said party, is this any better? Yes? No? Why, or why not?


Same question: if they aren't breathing, and they have taken some other drug, what will the downside be?


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## DrParasite (Mar 3, 2017)

A couple of years ago, me and this paramedic who I used to work with got into an argument on Facebook about the BLS use of Narcan.  Her argument was that EMTs cannot and should not be trusted with Narcan.  But she was completely in favor of cops giving Narcan to reverse ODs.  And the studies supported the idea that public access to narcan saves lives (I want to say the study was done in Boston, but it's been a few years).  

Suffice it to say, faced with hard facts, published studies, and the fact that giving Narcan to a person who hasn't taken opioids won't have a negative consequence, he personal bias to a level of training that only two years prior she was at would not let her admit that the data did not support her objection.  

So my personal opinion is this: if a drug is given over the counter, there is not reason why any EMS person should not be able to administer it.  Especially if it helps with a life threatening condition (don't get me started on how certain states won't allow EMTs to give baby aspirin for possible MI patients).

Back to the OP, I think we all can agree that giving Narcan WILL NOT restart a person's heart, WILL NOT end the CPR call, and WILL NOT fix the issue at hand.  However, assuming you get the person's heart started, you will still have the issues of the opiods in their system, depressing their respiratory drive, correct?  and while yes, this can be resolved using a BVM, wouldn't it be better for their body if they were breathing on their own?


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## VentMonkey (Mar 3, 2017)

DrParasite said:


> what are the downsides to this?  No wait, let me clarrify: other than the cost of the medication, or the false safety net, what will the negative patient outcome be for the patient?  Or are there any negative side affects, other than it won't work?
> 
> Same question: if they aren't breathing, and they have taken some other drug, what will the downside be?


I think you're missing the point entirely. Why don't you read the entire thread from beginning to end? 

And good for you for winning an argument on Facebook (shrugs)?


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## Handsome Robb (Mar 3, 2017)

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## EpiEMS (Mar 3, 2017)

Ginger care said:


> But thinking that there couldn't possibly be any bad side to _untrained _and _uneducated _people having it can be reckless.


Practically speaking, there is really very little evidence that there is a potential harm to expanding access to naloxone. Yes, perhaps the availability of naloxone might induce *some* users to continue using, but the number of people who might very well be "saved", if you will, exceeds that by orders of magnitude.


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## NysEms2117 (Mar 3, 2017)

I say this very rarely, but @Ginger care I truly think I have lost IQ points reading your posts. You struggle to portray a valid point, and you called somebody with an unmeasurable amount of intelligence(as compared to you) and idiot. I fully agree with @Remi and @NomadicMedic. You shouldn't be in civil service if you judge people like that.


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## DrParasite (Mar 3, 2017)

VentMonkey said:


> I think you're missing the point entirely. Why don't you read the entire thread from beginning to end?


no, I read it from start to finish..... I see your point, but your point doesn't negate my question....



VentMonkey said:


> And good for you for winning an argument on Facebook (shrugs)?


I think you're missing the point entirely.  Why don't you do review the studies on how beneficial public access narcan is?   

And more importantly, why don't you answer my questions?  

BTW, I agree we should give medications only if they are indicated.  But if it can help the patient (even if not in the immediate situation, but in the near future), why not?


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## EpiEMS (Mar 3, 2017)

DrParasite said:


> Back to the OP, I think we all can agree that giving Narcan WILL NOT restart a person's heart, WILL NOT end the CPR call, and WILL NOT fix the issue at hand. However, assuming you get the person's heart started, you will still have the issues of the opiods in their system, depressing their respiratory drive, correct? and while yes, this can be resolved using a BVM, wouldn't it be better for their body if they were breathing on their own?



Hold on a sec, if the cardiac arrest is secondary to an OD, why are we using resources to do something other than what we know works (CPR and defibrillation)?


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## DrParasite (Mar 3, 2017)

EpiEMS said:


> Hold on a sec, if the cardiac arrest is secondary to an OD, why are we using resources to do something other than what we know works (CPR and defibrillation)?


because once we get the heart started again, the body will still need to deal with the effects of the OD, which very likely caused the cardiac arrest.  if you don't treat the OD, it's very likely to reoccur.  and if we have extra hands to do some IN naloxone, while doing CPR and defib, is that really a bad thing?


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## cprted (Mar 3, 2017)

DrParasite said:


> because once we get the heart started again, the body will still need to deal with the effects of the OD, which very likely caused the cardiac arrest.  if you don't treat the OD, it's very likely to reoccur.  and if we have extra hands to do some IN naloxone, while doing CPR and defib, is that really a bad thing?


The cause of the arrest is hypoxia secondary to respiratory arrest. If you gets ROSC, the opiate won't cause them to rearrest unless you stop ventilating them.

Their problem is hypoxemia, not hyponarcanemia.


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## CALEMT (Mar 3, 2017)

EpiEMS said:


> Hold on a sec, if the cardiac arrest is secondary to an OD, why are we using resources to do something other than what we know works (CPR and defibrillation)?



It certainly won't help the secondary issue. Like you said high quality cpr and early defibrillation are proven for a full arrest. However, if you gain ROSC and your patient starts to breathe on their own you'll want something to block the receptors that opiants bind to. That's where narcan comes into play.


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## VentMonkey (Mar 3, 2017)

DrParasite said:


> no, I read it from start to finish..... I see your point, but your point doesn't negate my question....
> 
> I think you're missing the point entirely.  Why don't you do review the studies on how beneficial public access narcan is?
> 
> ...


Why? We'd be arguing similar points of views.


CALEMT said:


> That's where *conservative narcan* *pushes* comes into play.


No need to have a combative peri-arrested opiate OD flailing about.


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## EpiEMS (Mar 3, 2017)

DrParasite said:


> because once we get the heart started again, the body will still need to deal with the effects of the OD, which very likely caused the cardiac arrest.  if you don't treat the OD, it's very likely to reoccur.  and if we have extra hands to do some IN naloxone, while doing CPR and defib, is that really a bad thing?





CALEMT said:


> It certainly won't help the secondary issue. Like you said high quality cpr and early defibrillation are proven for a full arrest. However, if you gain ROSC and your patient starts to breathe on their own you'll want something to block the receptors that opiants bind to. That's where narcan comes into play.



@DrParasite and @CALEMT, I've got no concern with throwing on some IN naloxone if we've got the extra hands, that's totally fair. That said, if I've got a BVM, I can correct hypoxia - I don't need naloxone. Heck, it's operationally easier to deal with an apneic post arrest patient than a combative one, as @VentMonkey says.


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## GMCmedic (Mar 3, 2017)

This wont be a favorable opinion but I typically prefer intubation over Narcan in most cases.

I have never administered Narcan during a code and I dont see myself ever routinely doing so. 

I have no issues with OTC narcan or Police carrying Narcan. We will not replace it for PD so if they want to administer it to every unconscious person they encounter then go for it, doesnt affect our budget.

 However, i still believe PD can serve a greater percentage of the population if officers had oxygen and BVMs. Thats not mainstream enough though.

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## EpiEMS (Mar 3, 2017)

GMCmedic said:


> This wont be a favorable opinion but I typically prefer intubation over Narcan in most cases.



Any particular reason why?



GMCmedic said:


> However, i still believe PD can serve a greater percentage of the population if officers had oxygen and BVMs. Thats not mainstream enough though.



I certainly hope most do - in my response area, they are all EMRs (at minimum), and have AED, BVM, O2, and a trauma kit (oh, and naloxone).


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## GMCmedic (Mar 3, 2017)

EpiEMS said:


> Any particular reason why?
> 
> 
> 
> I certainly hope most do - in my response area, they are all EMRs (at minimum), and have AED, BVM, O2, and a trauma kit (oh, and naloxone).



Our Sherriffs office and town PD's are stretched thin. Its near impossible to get them to cuff anyone or ride along if needed. 

I was once told by an officer that if a patient gets violent I can just get in my bag of tricks and put them back down. I Dont see much point in waking them up from the start if thats what Im going to have to do. 

We currently have one department getting AEDs no other medical plans are in the works that ive heard of. Two departments have Narcan, the other two dont want it. At least they all have tourniquets.

And when I say stretched thin, we might have 8 cops total between 4 departments covering 400 square miles and 4 of those will be limited to their town limits. 

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## E tank (Mar 3, 2017)

This thread has taken a kind of surreal turn. I'm not always a fan of reality, so I'll wade in too...without respect to any of the above posts:

1. If I had a full arrest that came about from known narcotic induced apnea, I'd feel comfortable defending giving narcan or not giving it, or delaying giving it, depending on the patients initial response to therapy.

2. Mask ventilation carries it's own risks, such as, not being able to, gastric distention and acute lung injury 2/2 aspiration. Only the operator with mad mask ventilation and keen clinical assessment skills should ever, if at all, consider mask ventilation over narcan in a patient like this, imho. If a wild wake up is to be avoided, why not have someone mask ventilate and someone else feather in a few mcgs of  narcan until spontaneous respiration returns? 

Again. Stopped reading. Guilty. Just my $ 0.02


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## Eden (Mar 3, 2017)

I certainly dont think we should give narcan to every resus. And i also dont think cops/fire should. I'd rather have them focused on good chest compressions and aed use.
I would give narcan if i suspect opiate od etiology.
And about the raging narcaned patient
Our protocols state narcan is to be given until adequate respirations return.
So usually thats what we do, until we arrive in the ER then we push 2mg and throw them in.
Jking ofc lol


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## NomadicMedic (Mar 3, 2017)

Just as an aside, how many people are regularly slamming huge amounts of Narcan and having their patients wake up flailing and fighting? Do people still really do this? 

I've used a lot of Narcan. I worked in Yakima Washington. I used a LOT of Narcan.  And in my anecdotal experience, n=1, I have never, ever had an opiate overdose wake flailing and fighting.  Normally, after a half milligram of Narcan, they're breathing and if they're starting to wake up, awfully apologetic and embarrassed. 

Perhaps a bit more careful titration is in order?


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## VentMonkey (Mar 3, 2017)

NomadicMedic said:


> Just as an aside, how many people are regularly slamming huge amounts of Narcan and having their patients wake up flailing and fighting? Do people still really do this?
> 
> I've used a lot of Narcan. I worked in Yakima Washington. I used a LOT of Narcan.  And in my anecdotal experience, n=1, I have never, ever had an opiate overdose wake flailing and fighting.  Normally, after a half milligram of Narcan, they're breathing and if they're starting to wake up, awfully apologetic and embarrassed.
> 
> Perhaps a bit more careful titration is in order?


I'm not entirely sure, but figured it's something worth occasionally mentioning with the wide array of provider levels on the forum.


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## E tank (Mar 3, 2017)

Well, there's a reason it comes in 0.4 mg vials now as well.  It used to only come in 2 mg syringes. Folks learned the hard way. Hypertension, diaphoresis, agitation. Just figured that was what happened when narcotics got reversed. The idea of titration came a little later.


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## VentMonkey (Mar 3, 2017)

E tank said:


> Well, there's a reason it comes in* 0.4 mg *vials now as well.  It used to only come in 2 mg syringes. Folks learned the hard way. Hypertension, diaphoresis, agitation. Just figured that was what happened when narcotics got reversed. The idea of titration came a little later.


We---and I believe most services---carry 2 mg preloads nowadays, though our protocols call for incremental doses as I've highlighted in your post because of the vials carried on our ambulances in the past.

As far as learning the hard way, I think it's a fairly common mistake seen with green providers (I did it once or twice), and I think it also goes to show that it in fact is not exactly "harmless" either.

Does it beat having an apneic, and cynaotic patient? Absolutely, but following the directions on the box (or in your protocols) is definitely worth reiterating regardless of training received.

Antidote or not, too much of _anything_ in the wrong hands can cause ill effects ranging from mild, and preventable, to lethal. It's still not the first thing on my mind in an arrest, even of the opiate variety.


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## ArizonaEMT (Mar 4, 2017)

I think its funny to see everyone trying to say Narcan has side effects........ can someone tell me the side effect of death?

With as many opiate overdoses we see out here, I am surprised we do not see a lot more cardiac arrest protocols saying to give Narcan during the first round of resuscitation.


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## DesertMedic66 (Mar 4, 2017)

ArizonaEMT said:


> I think its funny to see everyone trying to say Narcan has side effects........ can someone tell me the side effect of death?
> 
> With as many opiate overdoses we see out here, I am surprised we do not see a lot more cardiac arrest protocols saying to give Narcan during the first round of resuscitation.


When a patient ODs from a narcotic what is the reason they go into full arrest? What are we already doing that fixes that issue?

If Narcan has zero side effect why do we not give it for neonates who come out with narcotics in their system? What happens if we give a bone cancer patient who is on high dose pain meds Narcan?


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## CALEMT (Mar 4, 2017)

ArizonaEMT said:


> I think its funny to see everyone trying to say Narcan has side effects........ can someone tell me the side effect of death?
> 
> With as many opiate overdoses we see out here, I am surprised we do not see a lot more cardiac arrest protocols saying to give Narcan during the first round of resuscitation.



If you have read most of the posts on here narcan in the full arrest setting isn't going to do much, if anything. The heart isn't working properly, the opiate overdose is the least of my worries at this point. The heart is either in pulseless v tach, v fib, asystole, or PEA. All of which narcan isn't going to fix. High quality CPR and early defibrillation for pulseless v tach and v fib are whats going to save the patient. Narcan is just going to block the opiate receptors in the brain. If you gain ROSC then yeah it'll help with reducing the amount of opiates binding with the brain cells. However, you're still going to be ventilating the patient. 

Edit: and like every drug and medication on the market, narcan has side effects...


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## StCEMT (Mar 4, 2017)

CALEMT said:


> If you have read most of the posts on here narcan in the full arrest setting isn't going to do much, if anything.


I don't disagree with you, just throwing an extra little bit for thought. I believe it was @Remi (correct me if I am wrong when you see this) that said a while back in another discussion that in high enough doses, heroin/opiates could be a sympatholytic. I personally have never come across an OD that I couldn't handle with .5 or 1mg of Narcan, but that doesn't mean much.


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## ArizonaEMT (Mar 4, 2017)

Desert Medic ...... Not quite sure what you mean by "neonates who come out with narcotics in their system? What happens if we give a bone cancer patient who is on high dose pain meds Narcan?"  

Neonates are totally different, and are supported by their mother, after birth they will go into withdraw and are given opiates to combat the effects of Neonatal Abstinence Symdrome.  I don't think I have heard about a case where a mother gave birth and the neonate could not breath on its own because of the opiates that were given during utero.  

In addition why would it matter if you gave a bone cancer patient narcan who was a code?  Is pain not better then death?  What if the cancer patient accidentally took to many opiates or intentional overdose which you are not aware of?


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## DesertMedic66 (Mar 4, 2017)

ArizonaEMT said:


> Desert Medic ...... Not quite sure what you mean by "neonates who come out with narcotics in their system? What happens if we give a bone cancer patient who is on high dose pain meds Narcan?"
> 
> Neonates are totally different, and are supported by their mother, after birth they will go into withdraw and are given opiates to combat the effects of Neonatal Abstinence Symdrome.  I don't think I have heard about a case where a mother gave birth and the neonate could not breath on its own because of the opiates that were given during utero.
> 
> In addition why would it matter if you gave a bone cancer patient narcan who was a code?  Is pain not better then death?  What if the cancer patient accidentally took to many opiates or intentional overdose which you are not aware of?


In those patients I was referring that Narcan does have size effects since it seems like you were trying to imply there are no side effects to Narcan. 

In the case of bone cancer actually death may sometimes be the better choice for them. And hey if they have a DNR and coded (doesn't matter what caused it) the odds are I am not going to be working them up.


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## CALEMT (Mar 4, 2017)

ArizonaEMT said:


> What happens if we give a bone cancer patient who is on high dose pain meds Narcan?"





ArizonaEMT said:


> In addition why would it matter if you gave a bone cancer patient narcan who was a code?



Maybe you should read up on a medication before you try to make a logical argument about it.


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## ArizonaEMT (Mar 4, 2017)

My point is opiate overdoses go into cardiac arrest primarily because of prolonged respiratory arrest.  As part of the resuscitation attempt why would it not be appropriate to push narcan in addition to ACLS drugs.  If the patient is an overdose and narcan is not started the patient is not going to be able to breath on their own, we all know or should know about patient outcomes in intubated patients. 

Out here our protocols state we do not attempt an advanced airway until 4 rounds of 200 compression with Epi given 1 mg IV/IO are given every 200 compressions.


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## CALEMT (Mar 4, 2017)

ArizonaEMT said:


> As part of the resuscitation attempt why would it not be appropriate to push narcan in addition to ACLS drugs.



Because narcan isn't going to solve the problem of the heart not beating. It's a unnecessary drug to give. Where in the ALCS algorithm does it state to give narcan? Were in your H's and T's does it state to tread a OD?


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## VentMonkey (Mar 4, 2017)

ArizonaEMT said:


> My point is opiate overdoses go into cardiac arrest primarily because of prolonged respiratory arrest.  As part of the resuscitation attempt why would it not be appropriate to push narcan in addition to ACLS drugs.  If the patient is an overdose and narcan is not started the patient is not going to be able to breath on their own, we all know or should know about patient outcomes in intubated patients.





CALEMT said:


> *Maybe you should read up on a medication before you try to make a logical argument about it*.


This^^^. I think you're missing a key link here. In the respiratory arrested opiate OD who is found in cardiac arrest, you have to focus on the cardiac aspect above all else before worrying about giving or considering Narcan.

Did the opiate contribute to their death in this instance? Sure, will it "revive them" when they're that far gone? Hardly. Fine if you want to give increments of Narcan post resuscitation with good reason, but I stand by what I said, I'm not worried about that immediately into a cardiac arrest patient regardless of their initial cause.

Also, what's funny about it having side effects, even in the peri-arrested OD? Someone in agonizing pain regardless of their lifestyle choices is hardly "funny" IMO, and shows a lack of decency and humanity.


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## DesertMedic66 (Mar 4, 2017)

ArizonaEMT said:


> My point is opiate overdoses go into cardiac arrest primarily because of prolonged respiratory arrest.  As part of the resuscitation attempt why would it not be appropriate to push narcan in addition to ACLS drugs.  If the patient is an overdose and narcan is not started the patient is not going to be able to breath on their own, we all know or should know about patient outcomes in intubated patients.
> 
> Out here our protocols state we do not attempt an advanced airway until 4 rounds of 200 compression with Epi given 1 mg IV/IO are given every 200 compressions.


If the patient still has pulses and has decreased respiratory drive from narcotics then by all means Narcan away. If the patient is in full arrest they are no breathing and will not magically start breathing right after you push the Narcan. That is why we breath for our full arrests. I have never seen nor heard of any full arrest where Narcan was pushed and the patient suddenly got ROSC right after the medication was administered.


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## ArizonaEMT (Mar 4, 2017)

CALEMT - "Because narcan isn't going to solve the problem of the heart not beating. It's a unnecessary drug to give. Where in the ALCS algorithm does it state to give narcan? Were in your H's and T's does it state to tread a OD?"

Well it's 2015 AHA ECC Guidelines 

Read about it here:
h t t p : / /  eccguidelines.heart.org/wp-content/themes/eccstaging/dompdf-master/pdffiles/part-10-special-circumstances-of-resuscitation.pdf


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## DesertMedic66 (Mar 4, 2017)

ArizonaEMT said:


> CALEMT - "Because narcan isn't going to solve the problem of the heart not beating. It's a unnecessary drug to give. Where in the ALCS algorithm does it state to give narcan? Were in your H's and T's does it state to tread a OD?"
> 
> Well it's 2015 AHA ECC Guidelines
> 
> ...


If you yourself actually read it you would know you just helped our case. In that article it states "
While there is no evidence that administration of naloxone will help a patient in cardiac arrest, the provision of naloxone may help an unresponsive patient with severe respiratory depression who only appears to be in cardiac arrest (ie, it is difficult to determine if a pulse is present)". In that link it is saying it may be reasonable for lay people or non HCP BLS providers to admin Narcan because for them it may be hard to tell if the patient has a pulse or not...


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## GMCmedic (Mar 4, 2017)

CALEMT said:


> Were in your H's and T's does it state to tread a OD?



Toxins

But I agree

ETA: i see they specifically address this further in AHA. I dont think ive ever actually read an ACLS book

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## CALEMT (Mar 4, 2017)

GMCmedic said:


> Toxins



Granted it crossed my mind, but would you consider an opioid overdose to be a toxic environment within the body? Sure the respiratory depression can cause respiratory acidosis, but in the full arrest setting thats already being addressed with positive pressure ventilations. Even then you're at Hydrogen ion (acidosis) which if metabolically will be addressed with administration of sodium bicarbonate. I see no reason to give narcan during the arrest. If you get ROSC like I've previously stated, it will be beneficial in blocking the opiate receptors in the brain and will help with ventilation efforts. I'm not arguing, but merely showing my train of though with Toxins in the H's and T's.


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## DesertMedic66 (Mar 4, 2017)

CALEMT said:


> Granted it crossed my mind, but would you consider an opioid overdose to be a toxic environment within the body? Sure the respiratory depression can cause respiratory acidosis, but in the full arrest setting thats already being addressed with positive pressure ventilations. Even then you're at Hydrogen ion (acidosis) which if metabolically will be addressed with administration of sodium bicarbonate. I see no reason to give narcan during the arrest. If you get ROSC like I've previously stated, it will be beneficial in blocking the opiate receptors in the brain and will help with ventilation efforts. I'm not arguing, but merely showing my train of though with Toxins in the H's and T's.


Normally with toxins they are talking about drugs such as a TCA overdose or BB or CB OD.


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## GMCmedic (Mar 4, 2017)

Ive always considered OD as well when referring to toxins, but like you I dont give Narcan in codes either so its irrelevant. 

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## ArizonaEMT (Mar 4, 2017)

The point is narcan is starting to be put into protocols for ECC.  I am sure more studies will come later on this.  

Good Points on Toxins....... we will see later if they consider this a nuerotoxin.


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## VentMonkey (Mar 4, 2017)

ArizonaEMT said:


> The point is narcan is starting to be put into protocols for ECC.  I am sure more studies will come later on this.
> 
> Good Points on Toxins....... we will see later if they consider this a nuerotoxin.


Heh?


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## VentMonkey (Mar 4, 2017)

Where this thread has gone:


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## DesertMedic66 (Mar 4, 2017)

ArizonaEMT said:


> The point is narcan is starting to be put into protocols for ECC.  I am sure more studies will come later on this.
> 
> Good Points on Toxins....... we will see later if they consider this a nuerotoxin.


They are putting it in as "reasonable" for lay people. Last I checked we are not lay people...


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## cprted (Mar 4, 2017)

ArizonaEMT said:


> CALEMT - "Because narcan isn't going to solve the problem of the heart not beating. It's a unnecessary drug to give. Where in the ALCS algorithm does it state to give narcan? Were in your H's and T's does it state to tread a OD?"
> 
> Well it's 2015 AHA ECC Guidelines
> 
> ...





			
				AHA said:
			
		

> Empiric administration of IM or IN naloxone to all unresponsive opioid-associated resuscitative emergency patients may be reasonable *as an adjunct to standard first aid and non-HCP BLS protocols*. Standard resuscitation procedures, including *EMS activation*, should not be delayed for naloxone administration.



Buddy, these are the Lay Rescuer guidelines, not the ACLS algorithms. That's why the algorithm has "Call 911" as part of the treatment. We don't expect the public to able able to accurately assess pulses, so we tell them if they don't seem to be breathing, start CPR, get an AED, call 911 (and possibly use a street narcan kit).

You've brought up treatable causes (Hs & Ts), which of those is the cause of arrest in an opiate OD?  Hypoxia.  What treatment do we have for hypoxia? Tubes and BVMs (while compressions and defibrillation is ongoing). Narcan does not reverse hypoxia in a patient who is in cardiac arrest.


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## Carlos Danger (Mar 5, 2017)

I don't think there is currently any evidence to support the idea of using naloxone routinely in cardiac arrest, and I'm not aware of any movements towards doing so. However - and I'm kind of playing devil's advocate here, but kind of not - why not try it? What makes it such a bad idea?

If you really understand the pharmacodynamics of opioids and naloxone, then you know that there IS more going on during an opioid OD than just respiratory depression. Respiratory depression is what we focus on because the majority of the time that is the primary cause of the arrest, and it is easily reversible. But in very high doses or in polypharm OD's, there's more at work than just the opioid slowing their breathing down to the point that they arrest, and the naloxone antagonizing the mU and Kappa receptors to get them breathing again. That's just the highly simplified version.

Did you know that naloxone is an effective vasopressor and inotrope, and that those effects are due to naloxone's effects on multiple receptors and pathways? Did you know that naloxone has reversed OD's of alpha2 agonists and ACEI's? Did you know that it has been shown to improve the chances of converting to a shockable rhythm when given to (non-OD) cardiac arrests? Did you know that it prevented deterioration of lactate and blood pH in hemorrhaging dogs, effectively blunting one of the big physiologic sequela of the low-perfusion state?

My point is not that I think we should start giving narcan to every arrest. I guess what I'm saying is that we should perhaps be a little more open minded to the idea of trying something new in cardiac arrest, and a little less committed to the dogma instilled by our paramedic instructors. Especially considering how little evidence exists to support what we already do, and how little dismal resuscitation rates remain.

I'd love to see a good study done on naloxone in cardiac arrest. It's a safe enough drug (with arguably fewer negative effects than high doses of epi) and the physiology involved could support a pretty strong hypothesis that it might be helpful.

Also, I think if you aren't using naloxone in cardiac arrest when an opioid OD is the suspected cause, just because "ventilation is what they need", you lack some understanding of what goes on during these arrests. It might not matter with a simple OD, and no, it isn't going to start the heart on its own, but it could potentially cause some physiologic changes that make resuscitation more likely, especially if the OD is due to some of the really potent opioids or a polypharm situation.


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## agregularguy (Mar 5, 2017)

Remi said:


> Did you know that naloxone is an effective vasopressor and inotrope, and that those effects are due to naloxone's effects on multiple receptors and pathways? Did you know that naloxone has reversed OD's of alpha2 agonists and ACEI's? Did you know that it has been shown to improve the chances of converting to a shockable rhythm when given to (non-OD) cardiac arrests? Did you know that it prevented deterioration of lactate and blood pH in hemorrhaging dogs, effectively blunting one of the big physiologic sequela of the low-perfusion state?



Interested in reading more on the conversion of shockable rhythms in non-OD arrests. I hadn't heard of that at all. Where did you read that?


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## StCEMT (Mar 5, 2017)

With an organized code, it's not like we don't have the time to give it at some point. I have to run it for at least 30 minutes anyway, I will eventually have a chance. Not that I think it will magically fix anything, but if ROSC is achieved then that is one thing I can cross of the list of things to worry about. By no means an immediate priority, but seems to be worth doing IMO.


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## cprted (Mar 5, 2017)

agregularguy said:


> Interested in reading more on the conversion of shockable rhythms in non-OD arrests. I hadn't heard of that at all. Where did you read that?


https://www.ncbi.nlm.nih.gov/pubmed/19913979

This is the one I'm aware of.


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## Carlos Danger (Mar 5, 2017)

cprted said:


> https://www.ncbi.nlm.nih.gov/pubmed/19913979
> 
> This is the one I'm aware of.


Yep. Small study, not overwhelmingly compelling by itself. But just one more reason why I think it should be looked at.


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## Handsome Robb (Mar 5, 2017)

Wasn't there something recently about opioids being cardioprotective during cardiac arrest? 

Edit: found it.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3757806/

Sent from my iPhone using Tapatalk


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## Bullets (Mar 12, 2017)

NomadicMedic said:


> Just as an aside, how many people are regularly slamming huge amounts of Narcan and having their patients wake up flailing and fighting? Do people still really do this?
> 
> I've used a lot of Narcan. I worked in Yakima Washington. I used a LOT of Narcan.  And in my anecdotal experience, n=1, I have never, ever had an opiate overdose wake flailing and fighting.  Normally, after a half milligram of Narcan, they're breathing and if they're starting to wake up, awfully apologetic and embarrassed.
> 
> Perhaps a bit more careful titration is in order?



So in NJ, BLS and PD protocol is 2mg IN. So guess what every single unconscious patient i go to gets from the cops before i arrive? 2mg IN Narcan. we have tried to teach them but it has been an uphill battle. Its probably 50% of my patients who come up agitated and combative.


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## VentMonkey (Mar 12, 2017)

Bullets said:


> So in NJ, BLS and PD protocol is 2mg IN. So guess what every single unconscious patient i go to gets from the cops before i arrive? 2mg IN Narcan. we have tried to teach them but it has been an uphill battle. Its probably 50% of my patients who come up agitated and combative.


What's your relationship like your local LEO's, and how well are your BLS providers taking to the protocol? Are they doing a better job than LE seems to be doing regarding judgement, and restraint with when to properly administer the Narcan?


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## DrParasite (Mar 13, 2017)

NomadicMedic said:


> Just as an aside, how many people are regularly slamming huge amounts of Narcan and having their patients wake up flailing and fighting? Do people still really do this?


I've seen it happen once, on an accidental OD on prescribed pain meds.... unfortunately, the patient happened to be a former linebacker and current LEO, so it was not fun during the first 30 seconds, but once he realized what happened, he was fine and grateful that we were there to keep him breathing and alive.

I have heard anecdotal stories about paramedics giving 2 mg of narcan and then leaving the room for BLS to carry the patient out, or giving 2 mg of Narcan as they are walking into the ER and letting the hospital staff deal with the projectile vomiting that follows.  \

The majority of ODs who get Narcan don't wake up fighting, despite what many senior paramedics tell their newbies; I've dealt with more combative drunks than opiod ODs.


VentMonkey said:


> What's your relationship like your local LEO's, and how well are your BLS providers taking to the protocol? Are they doing a better job than LE seems to be doing regarding judgement, and restraint with when to properly administer the Narcan?


Probably similar to mine: good guys, good at the LEO stuff, not so great at the medical side, but if they can save a life with narcan before EMS gets there, they will.  They are also the types who go into house fires with a fire extinguisher and try to put the fire out before the fire department gets there.

I do think the lack of oversight and accountability from a medical authority when it comes to LEO administered Narcan is one of the huge causes of this.


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## EpiEMS (Mar 13, 2017)

Bullets said:


> So in NJ, BLS and PD protocol is 2mg IN.



My protocol is the same, no room to titrate to effect. I have to say, I'd rather BVM for the 2 minutes it takes me to get a medic on scene (in the rare case that I'm not with one).


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## NomadicMedic (Mar 13, 2017)

EpiEMS said:


> My protocol is the same, no room to titrate to effect. I have to say, I'd rather BVM for the 2 minutes it takes me to get a medic on scene (in the rare case that I'm not with one).



It would give you the opportunity to practice your BVM technique. Something most providers could use.


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## EpiEMS (Mar 13, 2017)

NomadicMedic said:


> It would give you the opportunity to practice your BVM technique. Something most providers could use.



Yup, that's my preference. Same reason why it doesn't bother me (practically speaking) so so much to work a futile code.


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## usalsfyre (Mar 13, 2017)

NomadicMedic said:


> It would give you the opportunity to practice your BVM technique. Something most providers could use.


I cringe when I read this...unskilled BVM use has killed a lot of people.


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## NomadicMedic (Mar 13, 2017)

usalsfyre said:


> I cringe when I read this...unskilled BVM use has killed a lot of people.



Well, without Narcan and/or ventilation the guy dies. So, he should work on that BVM technique.


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## usalsfyre (Mar 13, 2017)

2mg IN rarely needs to be titrated, I'm not 100% sure what the fear is? IV naloxone is far more unforgiving.

Perhaps I've just seen too much ham handed BVM use.


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## VentMonkey (Mar 13, 2017)

My experience with IN Narcan has actually worked quite well. 0.5 in each nostril seems sufficient enough to get their respiratory drive up enough where I can move them from whatever floor they're found on, to the gurney, and then to the back of the unit just enough to reassess their mental status, drop a lock, and determine if they need anymore titrated for the trip to the ED.

A BLS provider _properly_ delivering breaths via BVM upon my arrival is simply an added bonus.


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## Bullets (Mar 13, 2017)

VentMonkey said:


> What's your relationship like your local LEO's, and how well are your BLS providers taking to the protocol? Are they doing a better job than LE seems to be doing regarding judgement, and restraint with when to properly administer the Narcan?


Generally pretty good. On a 100 man department we have probably 6ish current or former EMTs. But like @DrParasite said, their training has filled their heads with heroism and the media absolutely loves it. A headline a week "Local cops save man". We have been able to educate some, but its not uncommon to get radio updates of 1, 2, 3 narcans delivered prior to our arrival. 

Our BLS providers have no problems, but we just rarely get to use it because the cops carry 2-3 doses per cop.


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## E tank (Mar 13, 2017)

How routine is the use of an oral or nasal airway with mask ventilation for folks? Always? Sometimes? Hardly? Do you teach it?


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## NysEms2117 (Mar 13, 2017)

just as a reference Parole officers in the State of New york do not carry narcan in our cars. Police do, as well as state troopers.


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## VentMonkey (Mar 13, 2017)

Bullets said:


> Generally pretty good. On a 100 man department we have probably 6ish current or former EMTs. But like @DrParasite said, their training has filled their heads with heroism and the media absolutely loves it. A headline a week "Local cops save man". We have been able to educate some, but its not uncommon to get radio updates of 1, 2, 3 narcans delivered prior to our arrival.
> 
> Our BLS providers have no problems, but we just rarely get to use it because the cops carry 2-3 doses per cop.


Right, I worry this would be a similar effect if our local LEO's and/ or fire first responders were given this (even some overzealous EMT's, though they're theoretically easier to remediate in-house).

I'm not saying it shouldn't be an option, but as your example implies, the "hero mechanism" seems all too often to put blinders on these folks in spite of our best efforts, and intentions to properly educate them.


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## VentMonkey (Mar 13, 2017)

E tank said:


> How routine is the use of an oral or nasal airway with mask ventilation for folks? Always? Sometimes? Hardly? Do you teach it?


When I first started out, our company only stocked nasal trumpets in the BLS first-in bags (no clue why). Well, I would always ask our supply techs for a stack and they were usually kind enough to wrap one in each size in a rubber band, and I would stuff it in my first-in bag (same with the bougies, but another medic kindly swiped that without hesitation). I must not have been the only one bugging because now they're in every jump bag, ALS and BLS.

To answer your question though, tank I use NPA's whenever applicable, and appropriate with semi-conscious, and/ or unconscious--->soon to be conscious types...like an OD.


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## NomadicMedic (Mar 13, 2017)

I use an oral and a nasal every time I mask ventilate someone.

And 0.5 in the snout always seems like enough to get them breathing again. I rarely use any more than that. It's not uncommon to hear the ED doc order 2mg IV for a breathing, sleeping OD as I'm walking out. "Better you than me pal..."


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## DrParasite (Mar 13, 2017)

E tank said:


> How routine is the use of an oral or nasal airway with mask ventilation for folks? Always? Sometimes? Hardly? Do you teach it?


I always teach students to use an adjunct whenever they are using a BVM.   I typically start with an OPA, unless I think they are going to get better shortly (IE, an opiod OD or a witnessed arrest who arrests in front of me who i can shock immediately), then I might start with an NPA.  Or if they have a gag reflex, it's NPA or two.  

It makes such a difference.  I've seen a patient go from poor compliance prior to OPA to much better with OPA..... I tell people all the time, it makes things much easier for all parties involved.


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## E tank (Mar 13, 2017)

DrParasite said:


> It makes such a difference.  I've seen a patient go from poor compliance prior to OPA to much better with OPA..... I tell people all the time, it makes things much easier for all parties involved.



Absolutely...been doing this kind of work for 30+ years and I use an OPA on everyone I mask ventilate. So much of what we do is made easier by getting out of our own way, and using an airway to mask ventilate is definitely a biggie. 

C- mask ventilation can be brought up to a B- or B just by using one. Preach it Brothah!!!


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## StCEMT (Mar 14, 2017)

E tank said:


> How routine is the use of an oral or nasal airway with mask ventilation for folks? Always? Sometimes? Hardly? Do you teach it?


The last time I worked my way up the ladder. Got there and an off duty doc was bagging with positioning-->I got an OPA--> Then I replaced the OPA with an igel a  a little later. For me it's most of the time, it just depends on if we are going straight to an SGA or not.


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## EpiEMS (Mar 14, 2017)

E tank said:


> How routine is the use of an oral or nasal airway with mask ventilation for folks? Always? Sometimes? Hardly? Do you teach it?



Tube in every hole - double NPA plus an OPA. That said, I am lucky to have ALS with me 90% of the time, so it's usually just me BVM'ing with an OPA until they are dropping an ETT. Which, frankly, seems to be a waste for most of my calls - they are typically arrests due to cardiac cause, so time spent ETT'ing is time off the chest...right?


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## StCEMT (Mar 14, 2017)

EpiEMS said:


> Tube in every hole - double NPA plus an OPA. That said, I am lucky to have ALS with me 90% of the time, so it's usually just me BVM'ing with an OPA until they are dropping an ETT. Which, frankly, seems to be a waste for most of my calls - they are typically arrests due to cardiac cause, so time spent ETT'ing is time off the chest...right?


Although the exception rather than the norm in my limited experience, my last arrest is why I don't believe in jumping straight to intubation. You're awake? Cool, lets just pull this out.


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## EpiEMS (Mar 14, 2017)

StCEMT said:


> Although the exception rather than the norm in my limited experience, my last arrest is why I don't believe in jumping straight to intubation.



It's a systemic problem for me. We have CCR in protocols now, but when a salty medic says "Get outta the way, I'm going to intubate" even though we are so far from ROSC it's not even funny, I don't exactly have the ability to countermand that.


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## StCEMT (Mar 14, 2017)

EpiEMS said:


> It's a systemic problem for me. We have CCR in protocols now, but when a salty medic says "Get outta the way, I'm going to intubate" even though we are so far from ROSC it's not even funny, I don't exactly have the ability to countermand that.


Yea, I can see that being a tough spot, which sucks. Assuming I know the EMT is familiar with what we are doing, I absolutely want a partner who will ask questions before I do something if they have a concern. I see no reason you shouldn't be able to, but I also get that some folks get pissy because "the EMT shouldn't be questioning me".


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## DesertMedic66 (Mar 14, 2017)

Try to get the tube with compressions in progress. If you aren't able to then just go with a King. Easy as that for me haha


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## EpiEMS (Mar 14, 2017)

StCEMT said:


> Yea, I can see that being a tough spot, which sucks. Assuming I know the EMT is familiar with what we are doing, I absolutely want a partner who will ask questions before I do something if they have a concern. I see no reason you shouldn't be able to, but I also get that some folks get pissy because "the EMT shouldn't be questioning me".



I appreciate it - it is irritating, but it shouldn't happen. I try not to "question the medic", especially on scene, unless it is something truly critical, but I'd like to have a better rapport with the ones who give me tsuris.



DesertMedic66 said:


> Try to get the tube with compressions in progress. If you aren't able to then just go with a King. Easy as that for me haha



Hey, if they were good they could  Frankly, I think the evidence is at least as good for a SGA as an ETT, and probably (operationally) better when you consider hands off time for an ETT.


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## bwat16 (Apr 26, 2017)

nope


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## MikeC (Apr 27, 2017)

DrParasite said:


> I've seen it happen once, on an accidental OD on prescribed pain meds.... unfortunately, the patient happened to be a former linebacker and current LEO, so it was not fun during the first 30 seconds, but once he realized what happened, he was fine and grateful that we were there to keep him breathing and alive.
> 
> I have heard anecdotal stories about paramedics giving 2 mg of narcan and then leaving the room for BLS to carry the patient out, or giving 2 mg of Narcan as they are walking into the ER and letting the hospital staff deal with the projectile vomiting that follows.  \
> 
> ...


 
Our protocol states the goal of Naloxone use is mainly to restore one's respiratory drive, not to completely awaken them. It states ventilating/oxygenation of the patient takes priority over Narcan use.  So ultimately, the goal is to get the individual to the hospital alive, breathing, but not completely awake, alert and oriented. I like how they take into account the safety of EMS responders with the tendency of opiod ods to get violent with administration of narcan. We have a pretty bad area with opiod overdoses.


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