# Versed after Narcan for OD patients?



## Sally Jones (Mar 21, 2018)

What’s your opinion of giving Versed for possible combative behavior following Narcan administration that brought back respiratory drive?
Unresponsive patient, alcohol smell on patient, bloody new AC track mark, patient at known drug/ frequent 911 response location.


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## mgr22 (Mar 21, 2018)

Sally, I know this isn't an answer to your question, but was the Narcan titrated? Or is this all hypothetical?


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## SpecialK (Mar 21, 2018)

I'd just not give them the naloxone.

It's much easier to put in an LMA and ventilate somebody who might have a stuffed blue noggin and let the hospital slowly wake them up where they have lots of light and personnel and resources than in the back of an ambulance, or worse, on their lounge floor.


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## Sally Jones (Mar 21, 2018)

Narcan intranasal 2 mg given to unresponsive OD patient that had fresh track marks, alcohol smell at frequent 911 response location for similar calls. Not hypothetical.


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## Sally Jones (Mar 21, 2018)

SpecialK said:


> I'd just not give them the naloxone.
> 
> It's much easier to put in an LMA and ventilate somebody who might have a stuffed blue noggin and let the hospital slowly wake them up where they have lots of light and personnel and resources than in the back of an ambulance, or worse, on their lounge floor.



Yes I agree with you.


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## Sally Jones (Mar 21, 2018)

mgr22 said:


> Sally, I know this isn't an answer to your question, but was the Narcan titrated? Or is this all hypothetical?



Narcan intranasal 2 mg given to unresponsive OD patient that had fresh track marks, alcohol smell at frequent 911 response location for similar calls. Not hypothetical.


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## mgr22 (Mar 21, 2018)

Sally Jones said:


> Narcan intranasal 2 mg given to unresponsive OD patient that had fresh track marks, alcohol smell at frequent 911 response location for similar calls. Not hypothetical.



So, sounds like the combativeness was secondary to all-or-nothing, BLS-level dosing. I haven't been in that situation, but benzos have certainly been an option at the hospital for combativeness after excessive Narcan prehospitally.


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## Peak (Mar 21, 2018)

I would have rather supported their airway and respirations that have given the narcan in the first place. I would have bagged, dropped an LMA, or just tubed them depending on their presentation and how far we are from the hospital. Depending on how they were found and what there clinical presentation is they may have earned themselves imaging that is now going to be almost impossible, IV access will be more difficult, and arterial sampling will be near unobtainable. To me narcan is something we start on borderline patients when we don't want to tube in the ED, but either way they are likely to earn themselves an admission. I can only remember giving narcan once in the field and it was on a little old lady who accidently took too many MS Cotins after her hip surgery.

If someone gave narcan prior to my arrival and we now have a combative patient, yes you can give versed but understand that narcan does have some effects on benzodiazepines. You could also consider ketamine or haldol depending on clinical presentation. In the ED if we needed them back down for procedures I would plan on giving 1-2 mg/kg IV or 5 mg/kg IM ketamine.


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## Sally Jones (Mar 21, 2018)

mgr22 said:


> So, sounds like the combativeness was secondary to all-or-nothing, BLS-level dosing. I haven't been in that situation, but benzos have certainly been an option at the hospital for combativeness after excessive Narcan prehospitally.



Good info. And Yes BLS agency gave Narcan.


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## Sally Jones (Mar 21, 2018)

Peak said:


> I would have rather supported their airway and respirations that have given the narcan in the first place. I would have bagged, dropped an LMA, or just tubed them depending on their presentation and how far we are from the hospital. Depending on how they were found and what there clinical presentation is they may have earned themselves imaging that is now going to be almost impossible, IV access will be more difficult, and arterial sampling will be near unobtainable. To me narcan is something we start on borderline patients when we don't want to tube in the ED, but either way they are likely to earn themselves an admission. I can only remember giving narcan once in the field and it was on a little old lady who accidently took too many MS Cotins after her hip surgery.
> 
> If someone gave narcan prior to my arrival and we now have a combative patient, yes you can give versed but understand that narcan does have some effects on benzodiazepines. You could also consider ketamine or haldol depending on clinical presentation. In the ED if we needed them back down for procedures I would plan on giving 1-2 mg/kg IV or 5 mg/kg IM ketamine.



Good info. Thanks!


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## mgr22 (Mar 21, 2018)

Peak said:


> If someone gave narcan prior to my arrival and we now have a combative patient, yes you can give versed but understand that narcan does have some effects on benzodiazepines. You could also consider ketamine or haldol depending on clinical presentation. In the ED if we needed them back down for procedures I would plan on giving 1-2 mg/kg IV or 5 mg/kg IM ketamine.



Peak, I haven't heard of Narcan affecting benzos. Are we talking something anecdotal, or something evidence-based?


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## Sally Jones (Mar 21, 2018)

mgr22 said:


> Peak, I haven't heard of Narcan affecting benzos. Are we talking something anecdotal, or something evidence-based?



I have not heard of Narcan effecting benzo either.


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## Peak (Mar 21, 2018)

@Sally Jones @mgr22 

https://www.ncbi.nlm.nih.gov/pubmed/20573655

The effect is certainly not as great as with flumazenil, and the mechanism isn't fully understood, but narcan is known to have efficacy in treating benzos.


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## mgr22 (Mar 21, 2018)

Peak said:


> @Sally Jones @mgr22
> 
> https://www.ncbi.nlm.nih.gov/pubmed/20573655
> 
> The effect is certainly not as great as with flumazenil, and the mechanism isn't fully understood, but narcan is known to have efficacy in treating benzos.



Thanks, Peak. I was unaware of that.


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## Tigger (Mar 21, 2018)

Peak said:


> @Sally Jones @mgr22
> 
> https://www.ncbi.nlm.nih.gov/pubmed/20573655
> 
> The effect is certainly not as great as with flumazenil, and the mechanism isn't fully understood, but narcan is known to have efficacy in treating benzos.


Huh, who knew. Not me. 

I don't think I would have any issue giving some Versed (or Ativan) to this patient if it helped to facilitate their safe transport. We have the ability to manage their airway and not sedating and putting us at risk as a result is not worth the potential for mangeable respiratory compromise. As mentioned, Ketamine is also an option and lessens respiratory comprise risk for many.


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## VFlutter (Mar 21, 2018)

Are you talking about giving it prophylacticly for "possible" combative behavior before the patient even arouses? If so, that is not really appropriate.


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## medichopeful (Mar 21, 2018)

Sally Jones said:


> What’s your opinion of giving Versed for possible combative behavior following Narcan administration that brought back respiratory drive?
> Unresponsive patient, alcohol smell on patient, bloody new AC track mark, patient at known drug/ frequent 911 response location.



If they're unresponsive, why are you giving them versed?  Or was that the initial status?

Personally, if I had the option and HAD to re-sedate someone who has an opioid in their system, I would go with Ketamine.  Once that narcan wears off, the benzo/opioid mix is pretty potent.  After that would probably be Haldol.  I would try to avoid any benzos, but would use them if I had to.  

That being said, the best way to avoid this situation is to titrate narcan to respiratory drive, NOT consciousness.


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## TXmed (Mar 22, 2018)

Reasons these patients are combative after narcan administration

1. They are hypoxic
2. They are hypercapnic
3. They have a sympathetic surge 
4. Mixed use of drugs.

If you treated hypoxia and hypercapnia before giving narcan alot of it can be avoided.


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## cprted (Mar 22, 2018)

TXmed said:


> Reasons these patients are combative after narcan administration
> 
> 1. They are hypoxic
> 2. They are hypercapnic
> ...


This can't be emphasized enough. Too many people are so fixated on giving the supposedly "miracle life saving drug" that they forget to appropriately oxygenate and ventilate these patients.


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## StCEMT (Mar 22, 2018)

You can also just restrain your patient before giving anything and once they are awake and visibly calm, undo them. I know a few people prefer that route should they wake up. No messing with narcs and adding another drug to the mix.


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## Carlos Danger (Mar 22, 2018)

Sure, midazolam or ketamine can be used to calm a delirious or angry patient. But there's something about having to sedate a patient whose sedation you just intentionally reversed that should seem wrong on it's face. If your patients are routinely waking up unmanageable after getting naloxone, you are giving the naloxone wrong. You give just enough to restore respiratory drive, and no more. That way they slowly correct their hypoxemia and hypercarbia while they are still sleeping, and they don't have the huge sympathetic surge that can actually be life-threatening. Hitting someone with 2mg of naloxone right off the bat is a medication error, and the predictable result of that toxic dose of naloxone  is an unhappy, puking, hypertensive patient. 

Naloxone isn't a reliable reversal for benzos. You can find small studies and case series showing that all kinds of drugs have the ability to antagonize other drugs to some degree, even ondansetron. The effect isn't nearly potent enough or reliable enough to be included in any protocols though. 

There's always the option to provide mechanical ventilatory support rather than naloxone, and there's no question that that is sometimes the best option, depending on the scenario. Broadly speaking though, I think properly dosed naloxone is generally a better, safer option. Airway placement has risks (not the least of which is that these patients are at high risk for aspiration) and requires more resources and closer monitoring once at the receiving facility. 

Just place a NC and OPA or NPA (or provide ventilations if they are really hypoxemic) and give a small dose (0.1 - 0.4mg) of naloxone every minute or so until they start ventilating better and their Sp02 improves. You now have a calm, sedate patient who is breathing well. Monitor and transport. No versed, ketamine, or LMA needed. Easy peasy.


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## DrParasite (Mar 22, 2018)

Why are you waking up OD patient with Narcan?  I thought it was just to restore their respiratory drive.

Titrate till they're breathing, not until they become awake and combative.  No need for versed.


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## Tigger (Mar 22, 2018)

Remi said:


> Sure, midazolam or ketamine can be used to calm a delirious or angry patient. But there's something about having to sedate a patient whose sedation you just intentionally reversed that should seem wrong on it's face. If your patients are routinely waking up unmanageable after getting naloxone, you are giving the naloxone wrong. You give just enough to restore respiratory drive, and no more.





DrParasite said:


> Why are you waking up OD patient with Narcan?  I thought it was just to restore their respiratory drive.
> 
> Titrate till they're breathing, not until they become awake and combative.  No need for versed.



Unfortunately, with the advent of IN Narcan being available to anyone, we don't always get to control how our patient's receive naloxone. The "non-medical" training is to give 2mg of IN Narcan. There is a change (though less so with IN admin) of that resulting in an agitated patient. 

To be clear, I am willing to trade this potential adverse reaction for a patient that is breathing spontaneously prior to my arrival.


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## Sally Jones (Mar 22, 2018)

Remi said:


> Sure, midazolam or ketamine can be used to calm a delirious or angry patient. But there's something about having to sedate a patient whose sedation you just intentionally reversed that should seem wrong on it's face. If your patients are routinely waking up unmanageable after getting naloxone, you are giving the naloxone wrong. You give just enough to restore respiratory drive, and no more. That way they slowly correct their hypoxemia and hypercarbia while they are still sleeping, and they don't have the huge sympathetic surge that can actually be life-threatening. Hitting someone with 2mg of naloxone right off the bat is a medication error, and the predictable result of that toxic dose of naloxone  is an unhappy, puking, hypertensive patient.
> 
> Naloxone isn't a reliable reversal for benzos. You can find small studies and case series showing that all kinds of drugs have the ability to antagonize other drugs to some degree, even ondansetron. The effect isn't nearly potent enough or reliable enough to be included in any protocols though.
> 
> ...



BLS used intranssal 2 mg pre-load of Narcan. Titration a bit more difficult with IN route.


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## Carlos Danger (Mar 22, 2018)

Sally Jones said:


> BLS used intranssal 2 mg pre-load of Narcan. Titration a bit more difficult with IN route.



That is unfortunate. It's an inappropriate dose, and like any overdose, it will result in problems much more often than if they were able to use a smaller dose.


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## CANMAN (Mar 22, 2018)

Remi said:


> Sure, midazolam or ketamine can be used to calm a delirious or angry patient. But there's something about having to sedate a patient whose sedation you just intentionally reversed that should seem wrong on it's face. If your patients are routinely waking up unmanageable after getting naloxone, you are giving the naloxone wrong. You give just enough to restore respiratory drive, and no more. That way they slowly correct their hypoxemia and hypercarbia while they are still sleeping, and they don't have the huge sympathetic surge that can actually be life-threatening. Hitting someone with 2mg of naloxone right off the bat is a medication error, and the predictable result of that toxic dose of naloxone  is an unhappy, puking, hypertensive patient.
> 
> Naloxone isn't a reliable reversal for benzos. You can find small studies and case series showing that all kinds of drugs have the ability to antagonize other drugs to some degree, even ondansetron. The effect isn't nearly potent enough or reliable enough to be included in any protocols though.
> 
> ...



We are seeing this problem all over the state where I am at. Unfortunately pretty much every single city and county is seeing such high overdose rates that the hospitals don't have the patience or resources to continue treatment and monitoring or the patients who are treated as stated above. Baltimore, DC, many of the smaller cities with big drug problems are all giving at times 2 to 4mg of Narcan because if you coast in with a guy who has an NPA and a NC on and have only given 0.8 the first thing the RN's and MD's at all these hospital want to do is give them 2mg and wake them up. This has led to the field provider's in almost every single jurisdiction I am aware of giving 2 to 4mg depending on the substance to get the patient back online and then transporting them. There are city units running upwards of 8 unconscious overdoses a shift and I am not sure in those areas if it's practical to treat as above, especially when the process isn't supported as soon as you roll into the ED. Thoughts?


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## Carlos Danger (Mar 22, 2018)

CANMAN said:


> We are seeing this problem all over the state where I am at. Unfortunately pretty much every single city and county is seeing such high overdose rates that the hospitals don't have the patience or resources to continue treatment and monitoring or the patients who are treated as stated above. Baltimore, DC, many of the smaller cities with big drug problems are all giving at times 2 to 4mg of Narcan because if you coast in with a guy who has an NPA and a NC on and have only given 0.8 the first thing the RN's and MD's at all these hospital want to do is give them 2mg and wake them up. This has led to the field provider's in almost every single jurisdiction I am aware of giving 2 to 4mg depending on the substance to get the patient back online and then transporting them. *There are city units running upwards of 8 unconscious overdoses a shift and I am not sure in those areas if it's practical to treat as above, especially when the process isn't supported as soon as you roll into the ED.* Thoughts?



Wow. I guess in that case all you can do is what you can do. It sounds like a perpetual MCI.


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## VFlutter (Mar 22, 2018)

Not to condone it but I am sure a lot of that mentality is due to understaffed and overworked ERs. The Nurse to Patient ratios in most busy urban ERs is already woefully inadequate and an OD patient takes up a lot of resources. Especially leaving them in the semi-reversed state with a potentially tenuous airway. The quicker you wake them up the quicker they sign out AMA.


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## rescue1 (Mar 23, 2018)

We've been starting with 2mg IV in PA and going up from there. Lots of fentanyl around. Like CANMAN said, if we take them to the ED still unconscious they'll just get 2-4mg as soon as they get a bed (and usually immediately leave AMA). Honestly I've never seen any super bad combativeness that lasts for more than a minute or two, especially if you oxygenate the patient appropriately before they wake up. 

(Current record is 14mg in the field --> ICU on a naloxone drip.)


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## Sally Jones (Mar 23, 2018)

CANMAN said:


> We are seeing this problem all over the state where I am at. Unfortunately pretty much every single city and county is seeing such high overdose rates that the hospitals don't have the patience or resources to continue treatment and monitoring or the patients who are treated as stated above. Baltimore, DC, many of the smaller cities with big drug problems are all giving at times 2 to 4mg of Narcan because if you coast in with a guy who has an NPA and a NC on and have only given 0.8 the first thing the RN's and MD's at all these hospital want to do is give them 2mg and wake them up. This has led to the field provider's in almost every single jurisdiction I am aware of giving 2 to 4mg depending on the substance to get the patient back online and then transporting them. There are city units running upwards of 8 unconscious overdoses a shift and I am not sure in those areas if it's practical to treat as above, especially when the process isn't supported as soon as you roll into the ED. Thoughts?



 That is closer to what is happening in our area too.


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## DesertMedic66 (Mar 23, 2018)

Jeeze. The last time I gave narcan was probably 2 years ago. BVM for a couple of minutes to get SpO2 and EtCO2 normal and then 2mg IN and a 1 minute transport. We don’t get a lot of it here


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## CANMAN (Mar 23, 2018)

VFlutter said:


> Not to condone it but I am sure a lot of that mentality is due to understaffed and overworked ERs. The Nurse to Patient ratios in most busy urban ERs is already woefully inadequate and an OD patient takes up a lot of resources. Especially leaving them in the semi-reversed state with a potentially tenuous airway. The quicker you wake them up the quicker they sign out AMA.



Yup spot on...


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## CANMAN (Mar 23, 2018)

DesertMedic66 said:


> Jeeze. The last time I gave narcan was probably 2 years ago. BVM for a couple of minutes to get SpO2 and EtCO2 normal and then 2mg IN and a 1 minute transport. We don’t get a lot of it here



I give it at least once a shift when on the medic and this is a rural MD county. Units in the city of Westminster I would bet are administering at least 2-3 times a day. It’s crazy and sad.


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## ParamagicFF (Mar 30, 2018)

Remi said:


> Wow. I guess in that case all you can do is what you can do. It sounds like a perpetual MCI.



I work in this area and probably 50% of the calls I respond to overdoses of some variety. Generally it is heroin or K2. A day where I don't give narcan is a rarity. It's not uncommon for me to use it 5+ times a tour. I must say, with all of these countless ODs, I have never had anyone wake up violent with me from a heroin OD.

I came from a system where we started IVs and titrated narcan to respiratory drive. In my new system, I did that once and got a reality check from the ER staff. RN gave another 2mg narcan. Physician was by the bedside with "do you want help" paperwork. When the guy wouldn't even admit to drug use and told the doctor to get the f* out of his face, the doctor showed him the AMA paperwork. 

Our bed wait times are already long if you aren't a CPR, stroke, MI, or level 1 trauma. We would have to come close to doubling ER capacity if we were transporting all of our heroin overdoses. It's not ideal, but it's the reality. Common practice here is ventilate with BVM, 2mg narcan IM, and let them sign AMA when they wake up and say "I was just tired, I don't do drugs".


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## VinceVega91 (Apr 7, 2018)

If they wake up and start to fight, just keep yourself and your partner safe. Defend yourself, leave the scene, or let them leave the scene/truck and then eventually call PD to the scene if you have to. You're their to help these ingrates not fight or sedate them. They're not worth wasting anymore supplies, narcs, or resources. With that being said, double NPAs, 1-2 large bore (EJ) IVs, and repeated rapid sequence Narcan administration is usually the most appropriate care for these truly "sick" patients.


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## medichopeful (Apr 8, 2018)

VinceVega91 said:


> If they wake up and start to fight, just keep yourself and your partner safe. Defend yourself, leave the scene, or let them leave the scene/truck and then eventually call PD to the scene if you have to. You're their to help these ingrates not fight or sedate them. They're not worth wasting anymore supplies, narcs, or resources. With that being said, double NPAs, 1-2 large bore (EJ) IVs, and repeated rapid sequence Narcan administration is usually the most appropriate care for these truly "sick" patients.



You’re kidding, right? This post is meant to call out providers who actually do that and tell them that’s inappropriate and is an example of what not to do?  Right?

RIGHT?!


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## DrParasite (Apr 9, 2018)

VinceVega91 said:


> double NPAs, 1-2 large bore (EJ) IVs, and repeated rapid sequence Narcan administration is usually the most appropriate care for these truly "sick" patients.


I've seen an EJ put in once in the field.... are you seriously suggestions these patients need one on each side?


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## VinceVega91 (Apr 9, 2018)

DrParasite said:


> I've seen an EJ put in once in the field.... are you seriously suggestions these patients need one on each side?



Of course I'm joking. And no we don't do double EJs even though we often suggest the idea. It's just basic medical mischief. We treat these patients accordingly by adequately oxygenating their precious airways and brain cells as well as restoring their consciousness so that we can expedite the rehabilitation process for their "disease".


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## E tank (Apr 10, 2018)

VinceVega91 said:


> Of course I'm joking. And no we don't do double EJs even though we often suggest the idea. It's just basic medical mischief. We treat these patients accordingly by adequately oxygenating their precious airways and brain cells as well as restoring their consciousness so that we can expedite the rehabilitation process for their "disease".



Hard to say where the sense of gratification comes from for a minority of providers in EMS in being judge, jury and executioner to the patient's they have an obligation to treat. Assuming they even have the competency required to preserve or salvage "precious airways and brain cells" that they think they have, not being able to intellectually separate the provision of lifesaving care from ethical/values/human worth biases is troubling to say the least.

Good families that would otherwise "pass muster" with some of our more sanctimonious colleagues (imagine their relief) lose siblings and children to drug and alcohol addiction every day. It isn't something that happens for the gratuitous purposes of inconveniencing ambulance crews. 

If recognizing the humanity of patients is too much of a stretch, consider the professional disadvantages of such an attitude. Not being discrete about such opinions not only makes the person expressing them look like an absolute tool, it reflects poorly on everyone that brings patients to the hospital by ambulance. 

And people wonder why EMS workers don't get the respect they deserve.


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## johnrsemt (Apr 10, 2018)

I have had it happen twice in the last 6 months:  GCS of 3 (but breathing well on their own), just as we arrive someone gives Narcan internasally (because they are unresponsive, not because they aren't breathing):  now they are awake and pissed and combative; but still screwed up enough that we have to transport.  So we restrain them to the cot, and away we go; and sometime during the 2 hour transport they are still combative and causing problems in the back.  So yes I have given Versed. 
Personally I would rather bag them than wake them up that much,  but I have bagged someone for 2 hours, and that isn't fun either


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## johnrsemt (Apr 10, 2018)

And I miss doing EJ's.  conscious EJ's are the easiest, cause you get the patient to help.  and it doesn't hurt as much as drilling them.


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## VentMonkey (Apr 10, 2018)

The last narcotic-induced OD I recall popping an EJ in was on one I had thought about doing a dose of IN trial prior to, but then I spotted what appeared to be venous gold staring at me.

Anyhow, yeah I can’t really trump the level of articulation on behalf of @E tank. I just try and treat, and/ or fix what I can.

As far as their personal life-choices? I could care less. Professional marksmanship at its most simplistic.


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## VinceVega91 (Apr 10, 2018)

E tank said:


> Hard to say where the sense of gratification comes from for a minority of providers in EMS in being judge, jury and executioner to the patient's they have an obligation to treat. Assuming they even have the competency required to preserve or salvage "precious airways and brain cells" that they think they have, not being able to intellectually separate the provision of lifesaving care from ethical/values/human worth biases is troubling to say the least.
> 
> Good families that would otherwise "pass muster" with some of our more sanctimonious colleagues (imagine their relief) lose siblings and children to drug and alcohol addiction every day. It isn't something that happens for the gratuitous purposes of inconveniencing ambulance crews.
> 
> ...



If that’s the case then these patients would probably benefit more from a violin solo administered via room air. Unless these fools are in full arrest, I prefer to give as much Narcan as possible to wake them up. If they leave the scene, then great less work for me and my partner. They wanna fight, then great they get arrested, less work for me and my partner. If they get up and walk to the squad, then great, they get a wheelchair to the waiting room where they begin the triage process and my partner and I don’t even have to bring out the cot. Less work for me and my partner. It’s all about working smarter, not harder.



johnrsemt said:


> I have had it happen twice in the last 6 months:  GCS of 3 (but breathing well on their own), just as we arrive someone gives Narcan internasally (because they are unresponsive, not because they aren't breathing):  now they are awake and pissed and combative; but still screwed up enough that we have to transport.  So we restrain them to the cot, and away we go; and sometime during the 2 hour transport they are still combative and causing problems in the back.  So yes I have given Versed.
> Personally I would rather bag them than wake them up that much,  but I have bagged someone for 2 hours, and that isn't fun either



I can’t imagine riding in the back with a junky for that long. We’re pretty lucky to have a hospital on almost every corner. I suppose if they were that combative or just didn’t want to be transported, I would strongly encourage the patient exit the truck especially while it’s moving.


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## VentMonkey (Apr 11, 2018)

VinceVega91 said:


> Unless these fools are in full arrest, I prefer to give as much Narcan as possible to wake them up.


Ya know? I too remember being an arrogant 26 year old fool.

Anyhow, are you even old enough to appreciate the character that was _Vince Vega_? 

I guess I find your ironically dogmatic views and judgements somewhat perplexing given your chosen screen name; perhaps do your _Pulp Fiction_ homework.

Good luck to you, hopefully you grow up soon.


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## StCEMT (Apr 11, 2018)

I actually really like the EJ since they tend to trash decent peripheral veins/have massive EJ's waving like a flag in the wind. However, IM + NPA + BVM/NRB has become my new go to lately after a few not so pleasant IV results.


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## ParamagicFF (Apr 11, 2018)

For those of you experiencing "combative" patients after narcan administration, describe what you feel is combative behavior.
I treat A LOT of overdoses (or more often public doses), and at worst I find them to be uncooperative. Even those patients tend to be cooperative after a few minutes of explaining the situation and their options without judgement or hostility. 
Are you truly saying these people are attacking you unprovoked? I find that hard to believe.


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## FiremanMike (Apr 11, 2018)

ParamagicFF said:


> For those of you experiencing "combative" patients after narcan administration, describe what you feel is combative behavior.
> I treat A LOT of overdoses (or more often public doses), and at worst I find them to be uncooperative. Even those patients tend to be cooperative after a few minutes of explaining the situation and their options without judgement or hostility.
> Are you truly saying these people are attacking you unprovoked? I find that hard to believe.



This is generally what our experience is as well.  With that said, we do get the occasional patient who is truly combative and need to be re-sedated.  I'm genuinely curious as to the percentage now but our ePCR vendor is tying up my computer so I can't run the stats.  I'll try to remember to come back and evaluate the data tomorrow.


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## Carlos Danger (Apr 11, 2018)

VinceVega91 said:


> Of course I'm joking. And no we don't do double EJs even though we often suggest the idea. It's just basic medical mischief. We treat these patients accordingly by adequately oxygenating their precious airways and brain cells as well as restoring their consciousness so that we can expedite the rehabilitation process for their "disease".






VinceVega91 said:


> If that’s the case then these patients would probably benefit more from a violin solo administered via room air. Unless these fools are in full arrest, I prefer to give as much Narcan as possible to wake them up. If they leave the scene, then great less work for me and my partner. They wanna fight, then great they get arrested, less work for me and my partner. If they get up and walk to the squad, then great, they get a wheelchair to the waiting room where they begin the triage process and my partner and I don’t even have to bring out the cot. Less work for me and my partner. It’s all about working smarter, not harder.
> 
> 
> 
> I can’t imagine riding in the back with a junky for that long. We’re pretty lucky to have a hospital on almost every corner. I suppose if they were that combative or just didn’t want to be transported, I would strongly encourage the patient exit the truck especially while it’s moving.



Openly advocating for the abuse of vulnerable patients? Ooh so edgy and tough and cool. You’ll go far, brah.


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## michael150 (Apr 13, 2018)

VinceVega91 said:


> If that’s the case then these patients would probably benefit more from a violin solo administered via room air. Unless these fools are in full arrest, I prefer to give as much Narcan as possible to wake them up. If they leave the scene, then great less work for me and my partner. They wanna fight, then great they get arrested, less work for me and my partner. If they get up and walk to the squad, then great, they get a wheelchair to the waiting room where they begin the triage process and my partner and I don’t even have to bring out the cot. Less work for me and my partner. It’s all about working smarter, not harder.
> 
> 
> 
> I can’t imagine riding in the back with a junky for that long. We’re pretty lucky to have a hospital on almost every corner. I suppose if they were that combative or just didn’t want to be transported, I would strongly encourage the patient exit the truck especially while it’s moving.



I’m going to echo what everyone else else has said and hope you get it through your head. We joined this field to make a difference in people’s lives. The fact that you allowed to take care of patients with this mentality terrifies me and honestly bud, I think it’s time you go into a different field. 

Moving on.... I asked one of the attending physicians at work what he thought of this. His response? “You’re paramedics. Use the critical thinking skills we all know you have.” Basically, if the patient is totally unresponsive, give a whole 2mg over a course of 2-3 minutes spacing it out. We can basically send people into withdrawal (something we obviously don’t want) if we push too much at one time. Sooner or later though, the question becomes: should we intubate or secure their airway because obviously they aren’t waking up? As much as I think Versed, Valium, Ketamine are all good agents at controlling combative patients; we brought them out of one unresponsiveness, to put them into a different drug-induced one. If combative? Yes, it may be necessary. Honestly though, if we are taking them out of it slowly and reversing all the agents that can potentially cause the alteration of mental status, it shouldn’t be a fight. That’s my thought and he seemed to agree.


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## medichopeful (Apr 13, 2018)

VinceVega91 said:


> If that’s the case then these patients would probably benefit more from a violin solo administered via room air. Unless these fools are in full arrest, I prefer to give as much Narcan as possible to wake them up. If they leave the scene, then great less work for me and my partner. They wanna fight, then great they get arrested, less work for me and my partner. If they get up and walk to the squad, then great, they get a wheelchair to the waiting room where they begin the triage process and my partner and I don’t even have to bring out the cot. Less work for me and my partner. It’s all about working smarter, not harder.
> 
> 
> 
> I can’t imagine riding in the back with a junky for that long. We’re pretty lucky to have a hospital on almost every corner. I suppose if they were that combative or just didn’t want to be transported, I would strongly encourage the patient exit the truck especially while it’s moving.



Can administrators ban posters who have this attitude?


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## FiremanMike (Apr 16, 2018)

Finally managed to pull my data.

We primarily administer narcan via MAD which is given 2mg at a time (which I believe to be the standard for MAD dosing).  We have yet to find a sweet spot on MAD adminsitered narcan for "just breathing, not awake" so our patients generally go from unconscious to completely awake.

I pulled data back to November 2016 and found that only 1 patient required re-sedation with ketamine/versed after receiving narcan, N=165.


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## DrParasite (Apr 17, 2018)

FiremanMike said:


> Finally managed to pull my data.
> 
> We primarily administer narcan via MAD which is given 2mg at a time (which I believe to be the standard for MAD dosing).  We have yet to find a sweet spot on MAD adminsitered narcan for "just breathing, not awake" so our patients generally go from unconscious to completely awake.
> 
> I pulled data back to November 2016 and found that only 1 patient required re-sedation with ketamine/versed after receiving narcan, N=165.


I just want to say, you are one of my favorite firefighter posters on these boards.  no sarcasm at all, I love your EMS data driven concepts, your pro EMS points of view, if I could meet you and shake your hand, I totally would.

As to what you said, I don't think your standard is entirely accurate; the standard dose is UP TO 2 mg via MAD dosing, because there isn't really a concrete  number due to many variables (the patient, what they took, how much they took, etc).  Most places say titrate to effect, but if a little is good, a lot is even better.

So if 2 mg will get them up, walking and talking, and 1 mg will get them breathing and not awake, where now we need to carry them down to the truck, and take them to the ER where they will simply give another 2 MG to wake them up I think you see where this is going....  Not that I don't disagree with them, but I do think that keeping them unconscious but breathing, transporting them to the ER, only to have the ER push more narcan to wake them up and get them to sign out AMA makes me question why we don't just cut out the middle man and wake them ourselves.  

I can't recall any ODs (from  heroin or other) that needed to be chemically restrained; most were initially combative (waking up with 4 people they don't know hovering over them), but after that initial shock and some verbal calming down and explanation, they were fine.  Like you said, 1 in 165, that's a 0.6% occurrence, not very common.


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## FiremanMike (Apr 17, 2018)

DrParasite said:


> I just want to say, you are one of my favorite firefighter posters on these boards.  no sarcasm at all, I love your EMS data driven concepts, your pro EMS points of view, if I could meet you and shake your hand, I totally would.



Thanks, you're pretty squared away also!  I just gave my first conference lecture and it went well, I think I'm going to submit it to EMS World and see what happens, maybe we can meet up then!



> As to what you said, I don't think your standard is entirely accurate; the standard dose is UP TO 2 mg via MAD dosing, because there isn't really a concrete  number due to many variables (the patient, what they took, how much they took, etc).  Most places say titrate to effect, but if a little is good, a lot is even better.



I should have completed my thought by saying "the standard dose in this area".  As a matter of fact, the big city police department next door to us issues those 4mg nasal shooters to their officers, so that's where they start.. 



> So if 2 mg will get them up, walking and talking, and 1 mg will get them breathing and not awake, where now we need to carry them down to the truck, and take them to the ER where they will simply give another 2 MG to wake them up I think you see where this is going....  Not that I don't disagree with them, but I do think that keeping them unconscious but breathing, transporting them to the ER, only to have the ER push more narcan to wake them up and get them to sign out AMA makes me question why we don't just cut out the middle man and wake them ourselves.



I'll just be perfectly honest, I've never personally witnessed anyone administer "just enough" to get them breathing.  It's always "give them 2".. wait a few minutes.. still not awake or breathing.. "give them another".. rinse and repeat.  I'm not saying it's right, I know how it's supposed to go, I'm just saying how it's always gone in this area.. 



> I can't recall any ODs (from  heroin or other) that needed to be chemically restrained; most were initially combative (waking up with 4 people they don't know hovering over them), but after that initial shock and some verbal calming down and explanation, they were fine.  Like you said, 1 in 165, that's a 0.6% occurrence, not very common.



We get the occasional puker.. we get the occasional jerk-wagon.. but for the most part we just get the fully awake OD patient who's either embarrassed or (more commonly) defiantly refusing that they partook in opiate pleasure prior to our arrival.  We insist they go to the hospital, end up with refusals on about 3% of of them, and move on to the next one. 

We were actually awarded a federal DOJ grant this year to help address the opiate issues in our area, not sure how it'll pan out..


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## johnrsemt (May 8, 2018)

I usually start with approx. 0.4mg Narcan and go from there.

To the poster who was asking what we consider 'combative':  I usually consider it to be someone who is throwing himself around on the cot so much that even with 3 sets of seatbelts and soft restraints; the driver feels the truck moving.  Last guy popped the catch on the cot, so that the cot was moving around.   5mg Versed IM helped calm him down after a few minutes.


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## Summit (Jul 12, 2018)

Found an image, made a meme


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## FiremanMike (Jul 12, 2018)

Summit said:


> Found an image, made a meme



Ketamine blow darts..


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## johnrsemt (Jul 12, 2018)

Had a patient last weekend on a shift at my part time gig that was running into traffic screaming at cars to shoot him:  we talked about it on the way back from the hospital  "Last time I checked my car wasn't armed, and if it was it doesn't have a finger to pull the trigger". 
But the police got the patient down on the ground:  when we got there were 5 officers holding him down.   We gave him 5 mg Versed IM to start;  put 4 point soft restraints on his wrists and ankles; and then the officers lifted him to the cot (all of this on the street while 5 squad cars, and 2 ambulances had a 5 lane highway closed).  Secured him with the Seatbelts and 4 point restraints.   
  He bounced a few times; and was mainly verbally abusive during the 125 mile transport.   Kept talking to his father, mother and doctor (full body people sitting somewhere in the back of the ambulance).  Talking to his girlfriends head in the back window of the ambulance.   None of them where there, but he was having a good conversation with them.   Kept him calm.   Any time I tried to ask questions it upset him so I let him talk.
  Versed never really did anything to him.
   He admitted to Meth for 5 days;  that was the only consistent drug he admitted to;  sometimes he said that he took a lot of other stuff other times he denied anything else.  Always said Meth.

  Night before (before I worked) they had a drunk (pulled over for DUI and blew a 0.32) that was high with no idea of what.   He was fine until they started transporting him  (IV didn't even bother him):   10 miles out of town they are yelling for cops on the radio.   PD, fire and 2nd ambulance showed up for help.  He bit 1 FF on the hand who felt it through extrication gloves; bit a police officer on the leg, ripped his pants and drew blood.   He got 15 mg Versed and 10 mg Haldol, and fought the restraints for 105 miles.   He was tased 3 times one the side of the freeway, and 4 times on the way to the hospital (officer who was bit rode in with them).   
He never admitted anything but alcohol.

We think that we may have a bad batch of Meth out there;  But they like to mix up their own cocktails.    The only one I got to the hospital recently that I haven't had to sedate; that I was able to keep breathing with 13 doses of 0.4mg Narcan IVP during the transport ended up with Alcohol, Benzo's, Pot, Cocaine, Meth, X, and Opiates in his blood all at levels that the ED was shocked that he wasn't dead.


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## E tank (Jul 12, 2018)

Summit said:


> Found an image, made a meme



People in other fields would just write that off as being photo shopped. Can absolutely see that happening. And being forgotten the next day...oh the stories of the "hallway gurney"....notice the open electrical panel adjacent to the gurney...Staff were probably making bets on who buys beer after work if the guy could make it to the hot water pipes in the ceiling...


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## Phillyrube (Aug 29, 2018)

DrParasite said:


> Why are you waking up OD patient with Narcan?  I thought it was just to restore their respiratory drive.
> 
> Titrate till they're breathing, not until they become awake and combative.  No need for versed.



I put them on ETC02 and pulse ox.  NPA for the drill, and transport.  If their numbers are good, let them sleep.

I retired from the PD in 2014, and did a lot of the background on police narcan.   Still working as a 911 and ED medic, I saw a lot of the results.   Narcan given for every unconscious patient PD found.  Not the way I wrote up the protocols.   I started to make the cop who gave the narcan ride to the ED in tha back, to help me deal with whatever violent vomiting patient I had.  Other medics started that too, and when I left the system last year the amount of cop narcan had decreased, with no changes in mortality. 

I loved hearing the guys, "C'mon sarge, you can handle it"!!   Get in the truck!


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## DrParasite (Aug 29, 2018)

unrelated, but in the ED, if you have an unconscious opiod user who is breathing, what is done?  do they need a 1:1 monitor?  do they simply sleep it off like the people who enjoy too much alcohol?  or do the EDs give narcan?


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## Phillyrube (Aug 29, 2018)

DrParasite said:


> unrelated, but in the ED, if you have an unconscious opiod user who is breathing, what is done?  do they need a 1:1 monitor?  do they simply sleep it off like the people who enjoy too much alcohol?  or do the EDs give narcan?



I've seen both. Monitor, labs, clear C-spine (unconscious). Usually a CT scan.  If the numbers are good, they go on the monitor, monitored at the front desk, and let them sleep.  Sucks.


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## Peak (Aug 29, 2018)

DrParasite said:


> unrelated, but in the ED, if you have an unconscious opiod user who is breathing, what is done?  do they need a 1:1 monitor?  do they simply sleep it off like the people who enjoy too much alcohol?  or do the EDs give narcan?



It depends on the patient presentation and the region. If the patient can maintain their own airway but are hypercapnic/hypoxic despite O2 by NC we will given them just enough narcan (typically a small bolus and a titrated drip) to improve their ventilation and give some supplemental oxygen via NC. The patients will be on continuous monitoring by 3 lead, pulse ox, and capnography and are ESI 2 but are not typically 1:1 patients, often they are admitted to the unit but we may watch them in the ED if the unit is near capacity. If patient cannot maintain their own airway despite a reasonable amount of narcan then they will be intubated and will later be extubated in the unit, these are ESI 1 and will be 1:1 until they are tubed then 1:2 shortly after. We are pretty aggressive in prophylactic treatment of nausea/vomiting to prevent aspiration. Typically these patients are discharged within 1-2 days of presentation to the ED. If they are just mildly sedated but are maintaining a good airway and ventilatory status we typically put them on a monitor and put them in a hall bed in front of the nurses station (same as the drunks). We see relatively few opioid overdoses compared to other large metropolitan areas.

From what I've heard it isn't uncommon in the midwest or east coast to give massive narcan doses (I've heard that 10+ mg isn't uncommon) until the patient wakes up and then they... don't stop the patient from leaving very shortly after that. They also have relatively fewer ED beds for the population and it seems that the opioid additics take much larger doses.


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## ParamagicFF (Sep 1, 2018)

DrParasite said:


> unrelated, but in the ED, if you have an unconscious opiod user who is breathing, what is done?  do they need a 1:1 monitor?  do they simply sleep it off like the people who enjoy too much alcohol?  or do the EDs give narcan?



I transport to 6+ hospitals. Every one of them rolls their eyes if a heroin overdose ends up transported to their facility. They will immediately give narcan aggressively until the patient signs out AMA. They will generally draw labs on them as well in case there is more to the case, but little effort is made to keep them from AMAing. Another strategy they use is to not accept the patient into a bad for a while. They will have us wait in the hallway with the hopes that the patient will sober up and leave. This basically applies to any substance we transport.

Regarding the large doses of narcan, anecdotally I can say providers simply don't give it time to work. I've had 6 minute response times where the BLS crew that got there first says "We've already given 6mg with no change". And I've seen physicians order the same. The nurse barely has time to dispose of the IM injection needle before the MD is ordering more narcan. 

I think it's very much due to the system not having enough beds to support the amount of drug overdoses we take in a day. Between PCP, K2, and heroin, we can keep most of our beds full most of the day.


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## Bullets (Sep 2, 2018)

Our area cops have recently started carrying 4mg IN Narcan doses and let me tell you, its freakin wonderful pulling up to calls now where either the cops and the patient a rolling, the patient is violently vomiting and shivering, or just flat out seizing. At least with the 2mg the patients were usually awake but a little groggy. 

Weve been giving 500mg IM Ketmine for the guys who are fighting, usually 4mg for the seizures and O2 and everyone gets zofran


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## ParamagicFF (Sep 2, 2018)

Bullets said:


> Our area cops have recently started carrying 4mg IN Narcan doses and let me tell you, its freakin wonderful pulling up to calls now where either the cops and the patient a rolling, the patient is violently vomiting and shivering, or just flat out seizing. At least with the 2mg the patients were usually awake but a little groggy.
> 
> Weve been giving 500mg IM Ketmine for the guys who are fighting, usually 4mg for the seizures and O2 and everyone gets zofran



How often is behavior like this happening? I've read a few anecdotes like this on the forum, but never seen any similar behavior aside from the pt defecating, vomiting, or shivering. I've never seen violent behavior. And I run a LOT of heroin calls.

What adds more to my surprise is the fact that in my area, the patients would get away with acting violent towards police and EMS after getting narcan, so there's no reason for them not to. They usually wake up and say "Im good" over and over as they try to disengage and leave the scene.


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## Bullets (Sep 2, 2018)

ParamagicFF said:


> How often is behavior like this happening? I've read a few anecdotes like this on the forum, but never seen any similar behavior aside from the pt defecating, vomiting, or shivering. I've never seen violent behavior. And I run a LOT of heroin calls.
> 
> What adds more to my surprise is the fact that in my area, the patients would get away with acting violent towards police and EMS after getting narcan, so there's no reason for them not to. They usually wake up and say "Im good" over and over as they try to disengage and leave the scene.



Obviously my experience is anecdotal. Most departments have had this 4mg spray for about 2 months now. In that time we have had 6 patients who have needed sedation due to combative behavior post administration. I had yet to sedate anyone this calendar year. I know correlation doesnt equal causation and there may be some other chemicals laced in with this batch but in the ten years ive been doing EMS i never had a combative resus before July 1. Ive always said the same thing your saying, addicts dont fight, they just want to pull the sheet over their head and curl up on the cot.


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