# Narcan anyone???



## chief (Sep 8, 2013)

So I just found out I got hired at First Response in Chicago and am currently studying their SOP's. I came across something I never heard in their SOP's called Narcan. Never came across in my EMT book but it's supposedly common in the field. Supposedly, this reverses any effects of opiates or narcotics within minutes!!! Has anyone here ever used this first hand on a drug addict and did it pop them out of their high as quick as it says it does? Thanks for any responses!

Taqee


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## LACoGurneyjockey (Sep 8, 2013)

Narcan (naloxone) will block and reverse the effects of any opiate/opioid OD. Typically patients are violent and agitated upon regaining consciousness this way, so be prepared. A quick google search will tell you as much. 
And I can't imagine there isn't another thread already discussing this in depth...


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## chief (Sep 8, 2013)

Hey thanks for the reply. I've google'd it but just wanted to get a real world testament on the subject. The thought of someone high as a kite sobering up in mere minutes is shocking. Never heard of it.




> *LACoGurneyjockey:
> And I can't imagine there isn't another thread already discussing this in depth... *



I figured as much. How do you search old topics on here? Thanks again.

Taqee


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## chaz90 (Sep 8, 2013)

LACoGurneyjockey said:


> Narcan (naloxone) will block and reverse the effects of any opiate/opioid OD. Typically patients are violent and agitated upon regaining consciousness this way, so be prepared.



Eh, not necessarily violent and agitated when it's used correctly. 2 mg rapid IVP on a heroin junkie? Yeah, you'll turn your ambulance into the vomit comet and your comatose patient into something resembling a rabid mongoose. 0.5 mg or so titrated to effect through a variety of routes however and I don't mind Narcan at all. It is one of our more dramatic and immediately effective interventions. Between Narcan and D50 you can fool some people into thinking you're a wizard of the healing arts. Reference the "I be Banging" scene in Bringing Out the Dead for specifics...


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## LACoGurneyjockey (Sep 8, 2013)

For OP, search function on top right of the screen, "Search this Forum".

Nothing like a bringing out the dead reference to brighten my day. The only narcan I've ever used is the auto-injector, and it certainly is not "titrated to effect" (insert emoticon of furious junkie).


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## chief (Sep 8, 2013)

> For OP, search function on top right of the screen, "Search this Forum".



Hey thanks silly me.



> Reference the "I be Banging" scene in Bringing Out the Dead for specifics...



Ha! That was pretty funny! Never seen that movie before. The response "I be banging" lol, had to the Narcan was how I thought it would be. Still shocking!


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## Akulahawk (Sep 8, 2013)

chaz90 said:


> Eh, not necessarily violent and agitated when it's used correctly. 2 mg rapid IVP on a heroin junkie? Yeah, you'll turn your ambulance into the vomit comet and your comatose patient into something resembling a rabid mongoose. 0.5 mg or so titrated to effect through a variety of routes however and I don't mind Narcan at all. It is one of our more dramatic and immediately effective interventions. Between Narcan and D50 you can fool some people into thinking you're a wizard of the healing arts. Reference the "I be Banging" scene in Bringing Out the Dead for specifics...


I've used Narcan as well on patients. However, I have learned to use it very appropriately... Chaz's description of what it can do when it's used inappropriately is pretty much on the money. Of course, the patient will be very angry that you pretty much instantly wrecked their high and threw them into instant withdrawl if you use it wrong. 

Nice & slow IVP to bring up the respiratory rate... Much nicer to have a calm, blissed-out patient in your rig than one that's madder than Hulk.

And that's a GREAT scene from Bringing out the Dead!


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## the_negro_puppy (Sep 8, 2013)

Yep, we also landed on the moon OP


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## chief (Sep 8, 2013)

> Yep, we also landed on the moon OP



Ha! You should of seen me when I first heard about an AED!


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## Household6 (Sep 9, 2013)

Narcan is one reason why we make sure our restraints are on the rig and in good order..

I always thought Quintin Tarantino strove for accuracy in his movies, but that whole scene in Pulp Fiction where John Travolta shoots that giant needle in Uma Thurman's heart? Nope.


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## DesertMedic66 (Sep 9, 2013)

Narcan is a very very common medication. If I had to take a guess I would say it is probably our 3rd or 4th most used medication.


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## Achilles (Sep 9, 2013)

DesertEMT66 said:


> Narcan is a very very common medication. If I had to take a guess I would say it is probably our 3rd or 4th most used medication.



Would O2 be number 1?


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## DesertMedic66 (Sep 9, 2013)

Achilles said:


> Would O2 be number 1?



Yeah. O2, Albuterol, D50, Nitro, Narcan.


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## STXmedic (Sep 9, 2013)

Household6 said:


> Narcan is one reason why we make sure our restraints are on the rig and in good order..



If you frequently have to use restraints when waking someone with narcan, then you're doing something wrong. I've had to restrain exactly one person post naloxone, and that was because he was my first encounter with speedballing.


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## rob the mexican medic (Sep 13, 2013)

we use narcan almost every shift in new orleans. But it is pretty amazing the first time you see it. it works just like the textbook says it does. The things you don't learn in class.


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## the_negro_puppy (Sep 13, 2013)

DesertEMT66 said:


> Narcan is a very very common medication. If I had to take a guess I would say it is probably our 3rd or 4th most used medication.



I seen Narcan used twice in nearly 4 years


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## TheLocalMedic (Sep 13, 2013)

the_negro_puppy said:


> I seen Narcan used twice in nearly 4 years



Wow, so apparently no heroin or oxy abuse in Australia eh?  Here we're seeing more and more teens turning to straight up heroin after starting with oxy use.  

http://www.youtube.com/watch?feature=player_detailpage&v=CXJ8c0rWJsk


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## rmabrey (Sep 13, 2013)

Meh, its cool, but I prefer to just intubate them. Ive seen one to many OD's refuse after waking up.


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## TheLocalMedic (Sep 13, 2013)

rmabrey said:


> Meh, its cool, but I prefer to just intubate them. Ive seen one to many OD's refuse after waking up.



Da fuq?  I hope you aren't for real.  That's messed up man.  If you're so worried about them refusing, then just cut your dosage way down so that they're breathing but still dopey, then you can take them out of there no problem.  

Intubating an OD without trying narcan???  I bet you backboard anyone over 60 just to see them squirm too...  :angry:


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## TheLocalMedic (Sep 13, 2013)

rmabrey said:


> Meh, its cool, but I prefer to just intubate them. Ive seen one to many OD's refuse after waking up.



Also...  Said the medic student...  Didn't see that bit on your profile there...


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## rmabrey (Sep 13, 2013)

TheLocalMedic said:


> Da fuq?  I hope you aren't for real.  That's messed up man.  If you're so worried about them refusing, then just cut your dosage way down so that they're breathing but still dopey, then you can take them out of there no problem.
> 
> Intubating an OD without trying narcan???  I bet you backboard anyone over 60 just to see them squirm too...  :angry:



Actually no, I hate backboarding people, especially the elderly.


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## TheLocalMedic (Sep 13, 2013)

rmabrey said:


> Actually no, I hate backboarding people, especially the elderly.



Then why subject anyone else to discomfort and unnecessary procedures?  Intubating an OD?  REALLY?


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## TheLocalMedic (Sep 13, 2013)

Are you still just a student?  If so, bring that up in class and see how that goes over with your instructor.


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## STXmedic (Sep 13, 2013)

Yeah. Intubating an opiate OD just because you don't want a refusal (or for just about any reason) is pretty ridiculous. So much so that I'm hoping that was just a trolling comment.


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## Medic Tim (Sep 13, 2013)

rmabrey said:


> Meh, its cool, but I prefer to just intubate them. Ive seen one to many OD's refuse after waking up.



What is your thought process behind this? why is them refusing a bad thing? there are services that treat and release these pts.


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## Household6 (Sep 13, 2013)

I need to ask this, don't laugh at me.

Is it pronounced nah-LOX-on,

or

NAL-ax-on


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## RustyShackleford (Sep 13, 2013)

We always give it IM here unless there is serious respiratory depression, makes for a slower adjustment back into the reality of heroin withdrawl.


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## NomadicMedic (Sep 13, 2013)

Nah-LOX-own.


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## VirginiaEMT (Sep 13, 2013)

chief said:


> So I just found out I got hired at First Response in Chicago and am currently studying their SOP's. I came across something I never heard in their SOP's called Narcan. Never came across in my EMT book but it's supposedly common in the field. Supposedly, this reverses any effects of opiates or narcotics within minutes!!! Has anyone here ever used this first hand on a drug addict and did it pop them out of their high as quick as it says it does? Thanks for any responses!
> 
> Taqee



Give it to the in slow icrements. You want to increase their respiratory rate but let them stay unresponsive. If giving 2 mg give it to them in 0.4 mg. increments at a minute each. When their respiratory rate is adequate,STOP giving the Narcan. Capnography is perfect for this scenario!!

I have had a female patient who had overdosed on hydromorphone (dilaudud) who woke up after the first 0.4 mg, ripped out her IV and went nuts in the unit. It looked like a war zone.. THEY WILL GO NUTS ON YOU IF YOU WAKE THEM UP!!!


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## EMT B (Sep 13, 2013)

demedic said:


> nah-lox-own.



nar-kan


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## the_negro_puppy (Sep 14, 2013)

TheLocalMedic said:


> Wow, so apparently no heroin or oxy abuse in Australia eh?  Here we're seeing more and more teens turning to straight up heroin after starting with oxy use.
> 
> http://www.youtube.com/watch?feature=player_detailpage&v=CXJ8c0rWJsk



I spoke to soon. Gave 1.6mg IM Narcan (800mcg followed bys econd dose about 2 mins later) recently to a GCS 3 RR6 cyanosed OD on oxys and oral MS with no change after 10 mins of ventilation (difficult due to obese pt). Worked a treat, slowly but surely brought his GCS and resps up, topped up with 50mcg IV before transport. Was GCS14 with good resp status at hospital.
Nil combativeness, aggression or vomiting. Guy was a little annoyed asking why we didnt let him die.


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## chaz90 (Sep 14, 2013)

the_negro_puppy said:


> Worked a treat, slowly but surely brought his GCS and resps up, topped up with 50mcg IV before transport.



Do you mean 500 mcg or do you actually carry a concentration low enough that you can administer that low of a dose?


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## Carlos Danger (Sep 14, 2013)

rmabrey said:


> Meh, its cool, but *I prefer to just intubate them*. Ive seen one to many OD's refuse after waking up.



I just have to agree with the others in saying that I really hope you aren't serious....

Intubation is a risky procedure that is justified only when those risks are outweighed by the benefits. 

If there is no other way to secure the airway or maintain an adequate minute volume, then the benefits of intubation probably outweigh the risks. However, if you have a medication at hand that can safely reverse the respiratory depression, then opting instead to use a risky procedure is pure assault, IMO.

Many people talk about how "dangerous" nalaxone is, but frankly I think those people are dead wrong, and probably used to using toxic doses of it. I guarantee prehospital intubation causes far more problems than does prehospital administration of reasonable doses of nalaxone.



VirginiaEMT said:


> Give it to the in slow icrements. You want to increase their respiratory rate but let them stay unresponsive. If giving 2 mg give it to them in 0.4 mg. increments at a minute each. When their respiratory rate is adequate,STOP giving the Narcan. *Capnography is perfect for this scenario!!*



Exactly. This is one of those (relatively few, IMO) times where noninvasive capnography would be really useful. 

Dilute a 0.4 mg / 1ml vial in 9 ml for a 40mcg/ml concentration, and push 1-2 cc's at a time, watching the capnograph (or chest rise, if you don't have capnography).  



chaz90 said:


> Do you mean 500 mcg or do you actually carry a concentration low enough that you can administer that low of a dose?



Draw a up your entire 2 mg / 1 ml vial into a 10ml syringe and squirt half of it out. Then draw up 9.5 ml of NS so that you have 1 mg in 10 ml, or 100 mcg/ml. Push half a cc at a time = 50 mcg per dose.


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## jwk (Sep 14, 2013)

Halothane said:


> Dilute a 0.4 mg / 1ml vial in 9 ml for a 40mcg/ml concentration, and push 1-2 cc's at a time, watching the capnograph (or chest rise, if you don't have capnography).


I was hoping someone brought this up by the time I got through the whole thread.  This is exactly how I give it in the OR.  The idea is to get them to breathe adequately on their own, not wake up fighting. 

Not all narcotic OD's are junkies.  The rapid increase in sympathetic tone caused by high-dose narcan can precipitate all sorts of problems, particularly in older sicker patients, including causing pulmonary edema and even cardiac arrest.


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## Jambi (Sep 14, 2013)

Just to add to the fun. In my county here in California, we are specifically forbidden from titrating narcan. They just let us titrate Dextrose this year, but Naran is right out (sorry monty).  It's been brought up at committee meetings, and the medical director has spoken against it specifically.  If we use it we must give all 2mg as a bolus or IM or IN.


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## DrankTheKoolaid (Sep 14, 2013)

Jambi said:


> Just to add to the fun. In my county here in California, we are specifically forbidden from titrating narcan. They just let us titrate Dextrose this year, but Naran is right out (sorry monty).  It's been brought up at committee meetings, and the medical director has spoken against it specifically.  If we use it we must give all 2mg as a bolus or IM or IN.



Haha are you in SSV by chance? Their protocol reads the same way and the medics who work in the system I've spoke with are all puzzled why its written that way.


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## UKMEDICARABIA (Sep 14, 2013)

We use naloxone in the UK. 400ug IM route or IV, titrated to effect. With experience you learn to bring them round from respiratory depression but still leaving them a bit groggy.... Makes the Patient easier to manage, providing their respiratory system is improving and no longer hypoxic.  Also considered an essential drug to have with you when considering giving morphine.


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## exodus (Sep 14, 2013)

Halothane said:


> I just have to agree with the others in saying that I really hope you aren't serious....
> 
> Intubation is a risky procedure that is justified only when those risks are outweighed by the benefits.
> 
> ...



Few times capno is useful? We use it ALL the time, any respiratory patient or anyone that actually needs o2 will get side stream capno...


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## DesertMedic66 (Sep 14, 2013)

Corky said:


> Haha are you in SSV by chance? Their protocol reads the same way and the medics who work in the system I've spoke with are all puzzled why its written that way.



RivCo. I haven't looked at the protocols for it extremely well but I know we have a lot of medics who will titrate it.


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## Akulahawk (Sep 14, 2013)

Corky said:


> Haha are you in SSV by chance? Their protocol reads the same way and the medics who work in the system I've spoke with are all puzzled why its written that way.


I just read the SSV protocols... you're right. It _is_ written that very same way. Sacramento County's expressly says to titrate to adequate respiratory effort...:blink:


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## Jambi (Sep 14, 2013)

DesertEMT66 said:


> RivCo. I haven't looked at the protocols for it extremely well but I know we have a lot of medics who will titrate it.



Of we all know that done a certain way and documented a certain way are different things.  I am, of course, in no way advocating falsifying patient documentation, but I've also known a few that have done the same; especially when a known opiate frequent flyer is known to be violent when coming out of the OD.


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## JPINFV (Sep 15, 2013)

DesertEMT66 said:


> RivCo. I haven't looked at the protocols for it extremely well but I know we have a lot of medics who will titrate it.



Doesn't RivCo's ALS protocol start off with an awesome section about how the protocol is a guideline and that paramedics must use their own judgement when implementing it?


Edit:

Section 4101: Introduction to Treatment Protocols Page 3.
Standing Orders:
...
Standing orders are to be utilized as clinically indicated. Not every standing order in a treatment protocol must be carried out on every patient treated under that treatment protocol. Discretionary judgment is required


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## chief (Sep 15, 2013)

VirginiaEMT said:


> I have had a female patient who had overdosed on hydromorphone (dilaudud) who woke up after the first 0.4 mg, ripped out her IV and went nuts in the unit. It looked like a war zone.. THEY WILL GO NUTS ON YOU IF YOU WAKE THEM UP!!!



Talk about a dynamic job environment. Well I won't be seeing any of that action as we mostly deal with dialysis patients/pickups.....would love to be in a firehouse to get more experience such as this.


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## DrankTheKoolaid (Sep 15, 2013)

Even better and something I have come across multiple times lately is the clean needle exchanges giving out narcan. So you show up to a reported OD and the patient has already been given 0.4/0.8 by their partners in crime and is still in need of more


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## the_negro_puppy (Sep 15, 2013)

chaz90 said:


> Do you mean 500 mcg or do you actually carry a concentration low enough that you can administer that low of a dose?



We carry 400cmg /1ml. The drug was diluted by the Intensive Care Medic assisting us to a concentration of 500mcg / 10ml I believe (we only give the drug IM by ourselves)



Halothane said:


> Exactly. This is one of those (relatively few, IMO) times where noninvasive capnography would be really useful.



We had him on Etc02 nasal prongs once we stopped bagging him and switched him over to 02 mask.


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## Carlos Danger (Sep 15, 2013)

exodus said:


> Few times capno is useful? We use it ALL the time, any respiratory patient or anyone that actually needs o2 will get side stream capno...



Yes. I think a narc OD where you are titrating nalaxone is one of the few times in the field that capnography can make a real difference in how you manage the patient.

Just because you use something a lot doesn't mean it is useful.


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## Tigger (Sep 15, 2013)

chief said:


> Talk about a dynamic job environment. Well I won't be seeing any of that action as we mostly deal with dialysis patients/pickups.....would love to be in a firehouse to get more experience such as this.



Meh. That's not always how it goes down. They don't always fight, sometimes they're just wake up and they're pretty with it.



Corky said:


> Even better and something I have come across multiple times lately is the clean needle exchanges giving out narcan. So you show up to a reported OD and the patient has already been given 0.4/0.8 by their partners in crime and is still in need of more



Most of the programs encourage the person with naloxone to call 911 if they give it. Massachusetts is a leader in this and the program has been extremely successful. It's not always a "partner in crime," giving the medication to family of known addicts has been quite effective, with the family also being far more likely to call 911. Police officers in cities and towns with addiction problems were also provided with it several years before BLS ambulances were. naloxone is a BLS standing order in MA should the service choose to carry the drug. 

The information I had originally about the MA program was that the DPH was providing .4ml prefills with MAD devices for IN administration. Obviously .4 is often times not enough, but it may buy sometime before the ambulance arrives.


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## DrankTheKoolaid (Sep 15, 2013)

Yeah I'm sure that is true sometimes, I just haven't seen it that way..   Yet.


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