# 25/F overdose scenario



## rhan101277 (Mar 17, 2009)

You get a call that you have a 25/F with CPR in progress.  You arrive and find her breathing 3 times a minute, you find out from family members that she had taken some medicine recently.  Pupils are checked and you find them to be pinpoint.  You administer an appropriate dose of narcan.  The pt. comes around and is now AOx4.  

Wouldn't it be appropriate here to have you partner start bagging this pt with 15L/min o2?

What if it was an overdose, but not the type of drug that narcan will be able to help.  Do you just load and go and bag the patient.  If blood pressure is low give dopamine?

I just want to see what everyone else would do.

To give narcan and wait without bagging doesn't make since to me, because the 3 breaths a minute is going to create a grumpy heart and a grumpy brain.


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## Sasha (Mar 17, 2009)

At 3/min, you should be bagging a patient, regardless of what the problem is. Bag until they start breathing adequately on their own.

I've recently had narcan pushed on an OD patient of mine. It was a violent, vomity mess. It's also rather fast acting.

If it's not something that narcan can fix, supportive care and transport. You run into a lot of things you can't fix, an OD is just one.


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## Ridryder911 (Mar 17, 2009)

If she is breathing she is not in cardiac arrest. Dead heart=no respiration's. As well, I doubt I would call that breathing more than agonal respiration's. Second, I doubt Narcan would be effective as presented. Most  OD in arrest does not respond immediately as thought of when they are in that much trouble. Usually requires additional therapy.


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## EMT-B2B (Mar 17, 2009)

Should hook up 15 L per min with BVM with pt breathing 3 times per min.  Whats breathing rate after pt comes around?  Stop bagging or keep bagging? Couldnt the pt coming around possibly have an effect on the breathing rate?  I would definatley reassess after pt comes to.


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## rhan101277 (Mar 17, 2009)

Ridryder911 said:


> If she is breathing she is not in cardiac arrest. Dead heart=no respiration's. As well, I doubt I would call that breathing more than agonal respiration's. Second, I doubt Narcan would be effective as presented. Most  OD in arrest does not respond immediately as thought of when they are in that much trouble. Usually requires additional therapy.



I don't know the details but this was an actual call the other day and she did come around within 2 minutes.


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## BossyCow (Mar 17, 2009)

rhan.. you are overthinking... go back to basics.. one step at a time.. It doesn't matter if she's an overdose or other problem.. treat the problems you see as you are trained.

If she is not breathing well.. (under 8 ventilate) breathe for her. If upon regaining consciousness, her respirations improve, you may be able to stop. If she has a heart rate, she doesn't need chest compressions. Just slow down and look at the patient, and keep looking, before treatment, during treatment, after treatment... 

Ask yourself these questions.. What does the pt need? Can I give it to them? After I give it to them.. do they get better or worse or stay the same? Why?
Can I do something different? Does that help? Why or Why not?


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## 2630 (Mar 18, 2009)

kinda weird but i had something similair a few days ago....
toned for a possible DOA. arrive pov on scene to a 25/female. pt is pale in all extremities, blue in face, pink and warm in the core, and showing no signs of lividity. pt has no pulse and not breating. family states that the pt used heroine the night before and possibly just prior to her present status. i began cpr until my als crew arrived. pt has no medical history and unknown on allergies.
monitor applied and shows asystole. iv established and narcan and dextrose per my protocol were administered. pt intubated with no problems. pt transfered to squad where a second line was established and blood labs were drawn. requested a medic assist (the crew were intermediates) for the possibility of cardiac meds. upon arrival to ed pt developed a pulse at about 120 and shows a sinus tach on the monitor. she was placed on a vent but remained in a coma. rumor today is that they may take her off of life support.
moral of the story... treat your pt's signs and symptoms. start with the basics and go from there. whatever your pt throws at you, just role with it and see where you end up. sometimes it is just about handling the abc's and get to the ed.

2630


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## RielHalfbreed (Mar 18, 2009)

Agreed, treat your symptoms regardless of indicated injury/illness. 3bpm requires bagging.


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## vquintessence (Mar 18, 2009)

rhan101277 said:


> what if it was an overdose, but not the type of drug that narcan will be able to help.  Do you just load and go and bag the patient.  If blood pressure is low give dopamine?



Toxicology is practically limitless, and of all the drugs in my 18"x18"x10" box, i'd say we carry the antidote to < 1% (i love magic numbers).  Antidote/antagonists aside, primarily concerns lie with much of the same territory you will provide: Airway, suction, ventilations, and whatever good book they subscribe to can be best of treatments in the field.



rhan101277 said:


> to give narcan and wait without bagging doesn't make since to me, because the 3 breaths a minute is going to create a grumpy heart and a grumpy brain.



I assume most everyone here will say it's not acceptable to "wait for the narcan".  However, do you know how much narcan they gave and what route?  That will make a huge impact on how fast and severly the pt responds to treatment.  A lot of knuckleheads jam 2mg ivp, then get pissed when they're fighting somebody actively vomitting... But i'd guess that's why they're "waiting for the narcan".


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## Aidey (Mar 18, 2009)

You'll also get medics who aren't very sympathetic to their patients and give the whole 2mg up front just because they want to ruin the patients high rather than administer a smaller dose first. 

Our medical director is very very adamant that narcan should only be administered to the point that the patient has adequate respirations to support oxygenation. The only time we are supposed to administer the whole 2mg up front is in the case of severe respiratory compromise/respiratory arrest.

So in short, I would give 0.5mg (which is the starting dose under my standing orders) and bag the patient while waiting for it to take affect. I would also try and find out exactaly what she took and how much because you will need more narcan for some opiates than others.


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## SoCal (Mar 20, 2009)

Yes the Pt. needed bagging end of story. 

On a side note, I've been told to titrated to effect on the Narcan for your heroin overdoses, and as your pulling into a very slow ER slam the rest. (THIS IS A JOKE RESPONSE. DO NOT TAKE SERIOUSLY) 

Doing the above after you slam the Narcan, your pt. is very likley to start vomiting and possibly go into seizures, for those of you who were wondering what would happen if you did slam it. 

SoCal


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## vquintessence (Mar 20, 2009)

SoCal said:


> Yes the Pt. needed bagging end of story.
> 
> On a side note, I've been told to titrated to effect on the Narcan for your heroin overdoses, and as your pulling into a very slow ER slam the rest. (THIS IS A JOKE RESPONSE. DO NOT TAKE SERIOUSLY)
> 
> ...



Seizures from opiate withdrawal are slim to nill.  Barbitures and benzo's are another story, as their long term abuse can actually cause physical changes in the brain.  Immediate d/c of barb's and benzo's can lead to seizures and quite honestly the reason flumazenil was/is being taken out of service by a lot of EMS agencies.  The "SLOW" and "titrate to effect" was ignored by enough that EMS has lost support for carrying flumazenil.


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## Sasha (Mar 20, 2009)

> You'll also get medics who aren't very sympathetic to their patients and give the whole 2mg up front just because they want to ruin the patients high rather than administer a smaller dose first.



There are some who don't even just want to ruin the patient's high, I had a preceptor very early in medic school who felt that slamming narcan was a way to "punish" a drug addict by putting their body through hell. And this applied to everyone, little old ladies who forgot to take off their fentanyl patch before putting on a new one to the 20 year old hard and fast heroin addicts.

Sorry, I'm incredibly inexperienced and not yet a medic, so please be gentle, but if you can control their airway and bag, and there aren't other problems that need your attention on this patient, why push narcan at all?


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## JPINFV (Mar 20, 2009)

This is something I think gets a little lost in EMS. We work in teams for a reason. The answer in a suspected overdose like this is to do both. One provider can ventilate while the other is administering the narcan.


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## vquintessence (Mar 20, 2009)

Sasha said:


> Sorry, I'm incredibly inexperienced and not yet a medic, so please be gentle, but if you can control their airway and bag, and there aren't other problems that need your attention on this patient, why push narcan at all?



I'm confused by that and probably misinterpreting.  Are you asking why to ever give Narcan?  That we should be understanding and not disrupt their chemical dependence?

Have you ever had an opiate OD at or near respiratory arrest?  Concern then is to restore some of their own drive, as well as increase their LOC enough so that their gag reflex will ideally be intact.  Aspiration kills, ICU's are expensive, and how many drug abusers have private healthcare or life savings to pay for this?

I'd rather titrate to effect ANYDAY than intubate a pt who will benefit more from a gentle (yet disruptive) awakening than an intubation.  Are you prepared to walk into an ED with an intubated opiate OD and have your explanation be you didn't want to punish them?

Points aside, I hope you confronted your preceptor after the fact; he sounds sadistic.


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## SoCal (Mar 20, 2009)

vquintessence said:


> Seizures from opiate withdrawal are slim to nill.  Barbitures and benzo's are another story, as their long term abuse can actually cause physical changes in the brain.  Immediate d/c of barb's and benzo's can lead to seizures and quite honestly the reason flumazenil was/is being taken out of service by a lot of EMS agencies.  The "SLOW" and "titrate to effect" was ignored by enough that EMS has lost support for carrying flumazenil.



Thanks for that post, I only mentioned the seziures because i have personally seen it happen multiple times. I can't count the number of times my partner was asking other medics, I thought you had an OD, and they agreed and told my partner that they had given the full dose of Narcan. That's why i say that, but thanks for your point of view.


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## Sasha (Mar 20, 2009)

I worded my question wrong, sorry, but I got the answer I needed from various people. Thanks! :]


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## tfd86 (Oct 3, 2009)

I always manually open airway and intubate borderline apneic pt's found more than one fentynal patch that way.


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## MrBrown (Oct 4, 2009)

Yes I would bag the patient; maybe drop an LMA


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## redcrossemt (Oct 5, 2009)

tfd86 said:


> I always manually open airway and intubate borderline apneic pt's found more than one fentynal patch that way.



You never give enough narcan to increase their respiratory rate? Always intubate?


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## DV_EMT (Oct 5, 2009)

If they arent breathing on their own... bag 'em

If they are AOx3 I would assume that they're breathing OK and that 15Lpm on NRB would be ok.

Also... don't forget to sternal rub or trap pinch. sometimes reminding them to stay awake (pre-narcan) via sternal rub while on a NRB can help theim with respirations... I had to do that once when we didn't have a BVM readilly available.


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