# Narcan Question



## 82-Alpha599 (Jul 27, 2010)

hear is one example from yesterday, but it happens all the time with people I work with.

Get a life alert activation call.  on arrival no answer at the door, after a miniute we let ourselves in and see a 75ish y/o female sitting on the couch, alert to painful stimuli only.  
  no noted trauma
  Resps- 16-18 regular non-labored clear bilat
  HR-105 irregular
  BP- 86/61
  skin- pink warm very diaphretic (house probably 85 degrees inside)
  SpO2- 96 RA
  BGL- 110
  pupils 4-5mm sluggish
  ECG 3-lead - sinus arrhythmia (not a-fib confirmed by DR at ER)
  no med list or family available 


initial treatment
  O2 NRB
  IV 250ml NS bolus started

now someone wanted 2mg narcan IV
i said no because i saw no signs of narcotic OD

then all the sudden the pt woke up AxOx3, stated she felt dizzy then hit her life alert and that was the last thing she remembers.
12-lead obtained without ECG change.
after 350ml pt normotensive, HR 85-100

does every alterd LOC get narcan?
I dont, but we can if we want


second question

combined OD
narcotic, and ______ overdose.
narcan? or supportive treatment?


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## fyrfyter (Jul 27, 2010)

I am still very new to being a paramedic but given the respirations where 16-18 and not slow and shallow Narcan would not have been early at all in my treatment. I could be way off here.


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## Veneficus (Jul 27, 2010)

*Coma Cocktail*



82-Alpha599 said:


> now someone wanted 2mg narcan IV
> i said no because i saw no signs of narcotic OD
> 
> then all the sudden the pt woke up AxOx3, stated she felt dizzy then hit her life alert and that was the last thing she remembers.
> ...




Back in the day (probably about 15+ years ago now) There was often a EMS protocol called "Coma of unknown origin" which directed the administration of thiamine, narcan, and d50. 

It was based largely on unproven theories that have since been debunked or found to be more adventageous in a controlled setting, as well as being at a time when most EMS services didn't have finger stick glucometers. 

Unfortunately not only do many older medics still believe it to be a viable and adventageous practice, I have observed it is still taught under the guise of "the difference between what the book says and what happens in the street." 

Professionalism is a long way off.



82-Alpha599 said:


> second question
> 
> combined OD
> narcotic, and ______ overdose.
> narcan? or supportive treatment?



supportive treatment, let the ICU mix meds don't try in the back of a truck.


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## WTEngel (Jul 27, 2010)

Another thing to consider with administration of narcan is what exactly are you trying to achieve?

If I have a high index of suspicion for narcotic OD (which I would not in this case, there is nothing really pointing that direction), I don't necessarily want to bring the patient back around to fully CAO. In fact, really, I want them to be able to maintain their own airway, SPO2, and ETCO2, and that's about it. 

I have had partners in the past who advocated "slamming" the narcan in order to ruin the junkie's high, and it almost always ends with a combative, vomiting, dangerous patient. 

I point this out because, in your particular case, the patient was supporting her own airway, holding her sats, etc. The only thing that was really out of line was the BP. So there you go...treat the treatable. Bolus was a good choice, and it seemed to do the trick.

In answer to your original question though, absolutely NO, not every patient with altered LOC gets narcan. This is a very cookbook manner of thinking, and has someone pointed out earlier, is probably a result of the old school "coma cocktail" of narcan, thiamine, and d50. 

Treat the treatable, do no harm, take away the pain. 

TE


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## Phlipper (Jul 27, 2010)

> I have had partners in the past who advocated "slamming" the narcan in order to ruin the junkie's high, and it almost always ends with a combative, vomiting, dangerous patient.



Just a student ... but can confirm this one.  I had a former employee/friend OD on tar heroin while stopped at a gas station (shooting up in the car).  The Para hit him with Narcan and the employee says he "woke up and went nuts", and the guy with him confirmed it was a very bad scene.  Not sure that's something I'd want to deal with on top of everything else.


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## FF-EMT Diver (Jul 27, 2010)

I agree with not slamming Narcan to an OD if they can support themselves, however my response to these unknown unresponsive call are as follows

BG? <60 give D50
Pupils? Pinpoint gets Narcan.
Notable excessive ETOH gets Thiamine.

Sounds like your Pt. had a syncopal episode resulting from a drop in BP, coming from what is heard to say. Sounds like y'all did the appropriate tx and everything went well.


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## zmedic (Jul 27, 2010)

Though I agree with the above, I don't think that anyone would fault you for pushing some narcan. Elderly patients are usually on a lot of drugs, if you can't get a good history or drug list it's reasonable to suspect that a painkiller may be one of them. 

It wouldn't be the first thing I'd do, but after addressing most of the other causes of mental status changes that you can treat or detect (do a 12 lead, check a finger stick, give fluids etc) a dose of narcan would be reasonable. But not required.


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## ffemt8978 (Jul 27, 2010)

Veneficus said:


> Back in the day (probably about 15+ years ago now) There was often a EMS protocol called "Coma of unknown origin" which directed the administration of thiamine, narcan, and d50.
> 
> It was based largely on unproven theories that have since been debunked or found to be more adventageous in a controlled setting, as well as being at a time when most EMS services didn't have finger stick glucometers.
> 
> ...


We still have that protocol.:wacko:


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## Veneficus (Jul 27, 2010)

ffemt8978 said:


> We still have that protocol.:wacko:



Do you have one of those 10,000 page protocol books that instead of taking things out, they write an addendum that gets added in?


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## Aprz (Jul 27, 2010)

What about opiate triad (ALOC, inadequate resp., and miosis/pinpoint)? During my EMT ride along, we had what we believe was a heroin OD, however, the gentlement (ha, gentlemen) was still breathing adequately so naloxone wasn't administered (was consider unnecessary to do so) until we handed him over to the hopsital. He was already combative when we picked him up so we got to retrain him (that was an interesting experience for me). I believe the hospital also administered haloperidol (I asked, but I am not sure if I am remembering correctly) to relax him.

I'd say resp is the main thing though. Like WTEngel said, what are you gonna achieve by doing so?


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## ffemt8978 (Jul 27, 2010)

Veneficus said:


> Do you have one of those 10,000 page protocol books that instead of taking things out, they write an addendum that gets added in?



No, actually we have some fairly progressive protocols (in some aspects) with a lot of leeway for medics to exercise their judgment.  Our protocols are about 100-150 pages total, but we do have a written protocol for epistaxis.


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## feldy (Jul 27, 2010)

Phlipper said:


> Just a student ... but can confirm this one.  I had a former employee/friend OD on tar heroin while stopped at a gas station (shooting up in the car).  The Para hit him with Narcan and the employee says he "woke up and went nuts", and the guy with him confirmed it was a very bad scene.  Not sure that's something I'd want to deal with on top of everything else.



Yes...it can lead to some very unpleasant introductions with your pts. Be prepared and maybe restrain them prior to the narcan push. Also ripping out the iv you have just so beautifully placed is a common one. (Seen it done so many a time)


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## 82-Alpha599 (Jul 28, 2010)

thanks for confirming my thinking.  Sometimes I feel like the idiot when everyone else is against me.

Our protocol for Narcan is 2mg IV/IM/IO.  I usually start with 0.4 to 1mg depending on pt size, and give it really slow.  only twice have I had to give more than that.  One took 8mg, known Heroin OD, and the other 12mg Vicodin.

Even vicodin could be considered a combination OD eh? 
(hydrocodone & APAP)


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## feldy (Jul 28, 2010)

8mgs? The pt must of have been quite a large person or a possible frequent flyer of ODs?


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## jjesusfreak01 (Jul 28, 2010)

The short answer to your invisible phantom question feldy is...

No, Narcan doesn't have any uses other than treating narcotic problems. Its primary mechanism is binding to opioid receptions. The wikipedia article does mention one other use, in which it can treat patients who have complete insensitivity to pain, but that probably works by the same mechanism.


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## feldy (Jul 28, 2010)

haha yeah i though it was kind of a dumb question but wasnt sure. I read that same thing but that was the first i heard that so i wasnt sure if it was true.


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## 82-Alpha599 (Jul 28, 2010)

feldy said:


> 8mgs? The pt must of have been quite a large person or a possible frequent flyer of ODs?



oh yeah about 250lbs all muscle.  I was actually very afraid that he would wake up too much and want to fight.  thank god he was still lethargic after 8mg


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## lightsandsirens5 (Jul 28, 2010)

ffemt8978 said:


> We still have that protocol.:wacko:


 

I think that is state wide. We have the same thing, except, out MPD recently pulled thimine, and he is now putting a stop to the whole "coma coktail" idea, thank God.


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## MrBrown (Jul 28, 2010)

Naloxone would not be indicated in this patient simply because there is no evidence of opiod ingestion.


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## Veneficus (Jul 28, 2010)

82-Alpha599 said:


> oh yeah about 250lbs all muscle.  I was actually very afraid that he would wake up too much and want to fight.  thank god he was still lethargic after 8mg



Narcan also has a shorter 1/2 life than most opioids, sometimes depending on the opioid type/dose, a narcan infusion must be set up in order to keep them from reverting.


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## 82-Alpha599 (Jul 28, 2010)

Veneficus said:


> Narcan also has a shorter 1/2 life than most opioids, sometimes depending on the opioid type/dose, a narcan infusion must be set up in order to keep them from reverting.



im not saying you're wrong, but do you have any resources to prove that.  I looked before and could not find any that agreed on half life of heroin.

I don't think anyone knows the actual half life of street heroin, every batch is different.


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## Veneficus (Jul 28, 2010)

82-Alpha599 said:


> im not saying you're wrong, but do you have any resources to prove that.  I looked before and could not find any that agreed on half life of heroin.
> 
> I don't think anyone knows the actual half life of street heroin, every batch is different.



Not only have I seen it myself on multiple occasions, I offer:

Lippincott's Illustrated review of pharmacology 4th edition 
ISBN 13: 978-0-7817-7155-9. Page 168

It lists the 1/2 life of naxalone between 60-100 minutes and also goes on to say that an infusion or multiple doses may be required to prevent relapse.


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## 82-Alpha599 (Jul 28, 2010)

i agree. 
i was just wondering if anyone has a solid source for heroin half-life.


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## Veneficus (Jul 28, 2010)

82-Alpha599 said:


> i agree.
> i was just wondering if anyone has a solid source for heroin half-life.



Because of the variability of the constituants of street "heroin" as well as the phram kinetics and dynamics in the user, I don't think you will find any reliable source as to the halflife of it. 

Additionally synthetic opioids are designed to attach to receptors with high affinity which means they will also potentiate their action over a longer duration.

A street user may have subtheraputic levels and when shooting up increases the bioavailability considerably. Additionally they may also have some synergistic substances on board, substances that compete for conjugation enzymes or a decreased clearance from impaired hepatic or renal function. 

Based on all of this it would seem that measuring halflife of street drugs would have little benefit in determining treatment modalities in the EMS environment.


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## Aidey (Jul 28, 2010)

Methadone is another one that may require multiple doses of narcan or an infusion. 

For some reason the doctors around here continue to expect narcan to be administered in any ALOC patient, regardless of background. 

I understand that children could get into medication, or a person in a nursing home could be given someone elses medication so it should be considered in unlikely cases. But at the same time I would like some clinic judgment to be applied in ruling out opiates without having to give narcan.


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## MrBrown (Jul 29, 2010)

Somebody I know takes 120-250mg of methadone daily as well as 6-10 15mg benzos (clonazopam and oxazapam) and has done for thirty years.

Do you *really* think a little naloxone (or morphine or fentanyl for that matter) is going to work on him?


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## Jay (Jul 29, 2010)

A couple interesting points to go around...

The half life of nalaxone is roughly an hour to an hour and a half where most common analgesics such as oxycodone and hydrocodone are indicated every four to six hours, again there are variables but this shows the basic curves working against each other. The half life of methadone is AT LEAST 24 hours hence dosing >24 hours. That would suggest an IV/Narcan-drip would be necessary for such an OD.

As for additional uses it is an adjunct in Subaxone (along with Buprenorphine) in order to ensure that the person it is Rx'd to wont "shoot it up". Think about it, Nalaxone has almost NO oral-bioavailability and taken orally as part of subaxone wont work against the opioid as part of a replacement therapy. Subaxone is quickly becoming the drug of choice as an alternative to Methadone for addiction treatment or in some cases off label pain management in chronic cases.

Finally, the use of "slamming" nalaxone in the field may in my opinion be deemed cruel and unusual. There has at times been the debate of a nalaxone challenge in an ER/ED setting to simply see if someone is on opioids when there is suspicion that they are a drug seeker. If they have taken opioids you get the puking, headaches, y'all know the drill. In the field it can be the same results by "slamming". It can be a powerful drug to reverse OD when you have adequate proof one exists, e.g. the opioid triad, otherwise it would be a fine second-line method (when given humanely) after determining that other issues are not present, e.g. blood sugar or ETOH which can bear some but not all signs of similarity.

Just my $0.02 on the above comments.


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## Veneficus (Jul 29, 2010)

MrBrown said:


> Somebody I know takes 120-250mg of methadone daily as well as 6-10 15mg benzos (clonazopam and oxazapam) and has done for thirty years.
> 
> Do you *really* think a little naloxone (or morphine or fentanyl for that matter) is going to work on him?



If he is prescribed that, I would not use a reversal agent on him, it might put him into irretractable pain and limit my ability to control pain from there without a barbiturate. 

If he ODs we'll just ventilate him for a bit. If it requires long term we'll tube him and put him on a vent.


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## Melclin (Jul 29, 2010)

Veneficus said:


> Because of the variability of the constituants of street "heroin" as well as the phram kinetics and dynamics in the user, I don't think you will find any reliable source as to the halflife of it.
> 
> Additionally synthetic opioids are designed to attach to receptors with high affinity which means they will also potentiate their action over a longer duration.
> 
> ...





82-Alpha599 said:


> im not saying you're wrong, but do you have any resources to prove that.  I looked before and could not find any that agreed on half life of heroin.
> 
> I don't think anyone knows the actual half life of street heroin, every batch is different.



The serum half-life of heroin is generally said to be ~10 minutes. It moves across the blood brain barrier quickly where is then metabolized to a few things, namely morphine, which in turn has a longer half-life than naloxone. This is what our uni paramedic pain guru told me a while back, and this is the closest piece of literature I could find supporting it that I could link to: http://www.ncbi.nlm.nih.gov/pubmed/2420426

But "Kendall, J.M. and Latter, V.S.: Intranasal diamorphine as an alternative to intramuscular morphine: pharmacokinetic and pharmacodynamic aspects. Clin. Pharmacokinet. 42(6): 501-513, 2003." has a much better round up of its pharmacology.


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## 82-Alpha599 (Jul 29, 2010)

Jay said:


> Finally, the use of "slamming" nalaxone in the field may in my opinion be deemed cruel and unusual. There has at times been the debate of a nalaxone challenge in an ER/ED setting to simply see if someone is on opioids when there is suspicion that they are a drug seeker. If they have taken opioids you get the puking, headaches, y'all know the drill. In the field it can be the same results by "slamming". It can be a powerful drug to reverse OD when you have adequate proof one exists, e.g. the opioid triad, otherwise it would be a fine second-line method (when given humanely) after determining that other issues are not present, e.g. blood sugar or ETOH which can bear some but not all signs of similarity.




That sounds pretty dumb. Just do a blood tox or urine test.


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## Aidey (Jul 30, 2010)

I think part of that is a patience thing. It takes 2 minutes to push narcan, it can take 20 to 2 hours to get lab results back.


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## Jay (Jul 30, 2010)

I was thinking that there are "instant" tests for opioids that are available commercially. Via urinalysis you will have the results within 5 minutes, I believe that Calloway Labs manufactures one for Pain Management (verification) use that will give both instant results plus allow an MRO to confirm the results with an "independent" study later on. This of course is a requirement in physical medicine where opioid administration is both necessary and strictly controlled. The problem at hand is that there are certain physicians that would rather simply perform a narcan challenge may it be they are a lazy burnout of 25 years on the job or perhaps they are a resident who thinks that it will get a quick rise of s--ts and giggles to get him/her past their first __ (fill in the blank) hours that shift; either way there are easier and better ways of doing the job without jeopardizing the health and dignity of the patient.


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## 82-Alpha599 (Jul 30, 2010)

it isnt only unethical but dangerous.  You could send someone into withdrawals, may it be a junkie, or a cancer pt who accidentally took and extra vicodin today.  Plus now they may be in pain until the narcan wheres off and some narcotic can take effect again.


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## Veneficus (Jul 30, 2010)

*if I could just ask?*

In both pain management and palliative care, there is considerable use of opioids.  

Narcan is usually deemed as an emergent reversal agent, and as already pointed out on several posts, there are times when you wouldn't want to use it. (most of the time)

If the patient is in an uncontrolled setting (out of hospital) and suffering from a life threatening respiratory depression or hypotension perhaps, but why else.

Both of these conditions are quite well controlable with both ventilation and an airway adjunct, if need be intubation, and some fluids. Before pushing the narcan (just enough to potentially get away from a life threatening depression) 

In a healthcare facilty, in an emergent patient, the same situation applies. There is absolutely no reason to "wake somebody up." Even if you have to maintain them via drip in a depressed state. If the ICU is full they can be sent somewhere else that isn't.

In a clinic, administering PO opioids, they should be capable of controlling an airway until EMS can arrive and cart the pt off to a more capable facilty if longer term care is required.

Same day surgery should have some type of post anesthesia care available and really shouldn't raise any issues.

What then is the point of acute reversal?

So you have to wait a few minutes to a few hours for a tox? Who cares?

What is the point of "strict regulation" of opioids? If the patient is an addict, they'll get them somewhere. As well patients respond differently to different substances and doses for various reasons.

You detect opioids in a patient complaining of pain so you plan to give them no more? "Sorry you already had some opioids so we are going with an NSAID?"

This thread is starting to make no sense to me.


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