# Narcan question.



## jgav07 (Dec 1, 2011)

I have noticed alot of reluctance to giving narcan in quite a few of the threads and I was just wondering the reasoning behind this. I don't know if I am missing something. I know in my MCA we use narcan all of the time and I have never seen nor heard of any problems from its use other than, vomiting and combativness. I'm a new medic and just want to be sure im getting it all down pat. Thanks.


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## Nervegas (Dec 1, 2011)

jgav07 said:


> I have noticed alot of reluctance to giving narcan in quite a few of the threads and I was just wondering the reasoning behind this. I don't know if I am missing something. I know in my MCA we use narcan all of the time and I have never seen nor heard of any problems from its use other than, vomiting and combativness. I'm a new medic and just want to be sure im getting it all down pat. Thanks.



I believe the point you are discussing is that some medics, myself included, feel that not every unc/unr patient needs the ol' "coma cocktail", that liberal use of narcan just because is a waste and that nothing beats a good pt assessment. I am not against giving narcan in the right situations, but going to it first and often isn't what I would do.


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## jgav07 (Dec 1, 2011)

Not necisarilly the coma cocktail, but alot of people have stated that they would give it for pinpoint pupils, resp depression and altered loc. That confused me a bit.


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## jgav07 (Dec 1, 2011)

Wow terrible spelling to I look smart.


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## Shishkabob (Dec 1, 2011)

The issue?  Slamming it, where vomiting and combativeness are the least of your worries.  Others include arrythymias and possible arrest from sudden withdrawl.


However, if you push it smartly, there's little reason to be worried, and little reason not to do it for an unconscious of unknown etiology.


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## Nervegas (Dec 1, 2011)

jgav07 said:


> Not necisarilly the coma cocktail, but alot of people have stated that they would give it for pinpoint pupils, resp depression and altered loc. That confused me a bit.



I would say that those three signs would be a clue to _give_ narcan, not withhold it? I think you meant that they would _not_ give it in those instances? In which case, I would agree with your original point of it being confusing.


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## jgav07 (Dec 1, 2011)

Okay, that clears it up then. Thanks for the help.


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## jgav07 (Dec 1, 2011)

Correct nervegas I meant people were not giving it sorry.


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## MICP (Dec 1, 2011)

*"titrate"*

There is an often forgotten or untaught technique with medication administration called "titration".  For those who have taken a chemistry course, we remember doing this as we mixed two chemicals until we saw the desired effect (I understand this is a very loose definition of titration).  This is most useful with Narcan administration especially when there is suspicion of polypharmacy, like a patient who has taken a "speed ball", a mixture of morphine or heroin and cocaine.

They have the respiratory depression that needs managed and the pinpoint pupils scream opiate, but the possibility of cocaine being unabated by the CNS depressant can be a concern.  So why not give the Narcan in 0.4 mg increments until a rise in the respiratory status?

For those systems where the combative behavior cannot be readily managed pharmacologically, this allows the patient's own medicine (opiates) to keep them chemically sedated while still following the appropriate steps to manage the respiratory depression associated with the opiate itself.

This same principle is applicable with D50, especially in the case of a "mixed bag" of complaints...slurred speech, unilateral weakness, hypertension, but pale, cool, moist...that could be a stroke or hypoglycemia.  So you do an accucheck and it comes back at 40.  You know all of the associated risks with injecting this hypertonic necrotizing agent in the blood stream of someone have a stroke, especially a hemorrhagic one, but the blood sugar is low.

Give half the amp!  Reassess v/s and blood sugar, and if it is normal and symptoms persist, it was also a stroke.

Titrate.


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## NomadicMedic (Dec 1, 2011)

I find it amazing that more medics don't practice the "titrate until effect is reached" rule. I like to draw my Narcan up in a flush and just infuse it bit by bit until I see an increase in respiratory drive. In many cases it doesn't even take the 0.4mg that I've drawn up. The same with D50 and, in some select cases, morphine.


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## emtvic17 (Dec 5, 2011)

give em 0.5 mg, just enough to get their respirations up, keep em happy sleeping, and avoid the projectile vomiting =), if respirations go below normal range, hit em with another 0.5mg. And if you hate the ER staff, push the rest to bring em back and leave em with some nice cleaning up to do.


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## NomadicMedic (Dec 5, 2011)

emtvic17 said:


> And if you hate the ER staff, push the rest to bring em back and leave em with some nice cleaning up to do.



I hope you're kidding.


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## 18G (Dec 5, 2011)

emtvic17 said:


> give em 0.5 mg, just enough to get their respirations up, keep em happy sleeping, and avoid the projectile vomiting =), if respirations go below normal range, hit em with another 0.5mg. And if you hate the ER staff, push the rest to bring em back and leave em with some nice cleaning up to do.



Usually Narcan is given in 0.4mg increments (based on standard rule). I've given it in 0.2mg increments as an attempt to not cause complete blockade of the opiate I had given as ordered for pain management. It wasn't successful. With 0.4mg pt. was fully aroused and back with level 7 pain. Fentanyl did work to take some of the edge off though post-Narcan.


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## NomadicMedic (Dec 5, 2011)

In overdoses with respiratory depression, I draw up 0.4 in a 10ml flush and titrate the administration to an increase in respiratory drive, not to being fully conscious. 

If you're pushing 2mg to be a hot shot or "punish" the PT for overdosing, you should have your hand slammed in a door. It's inexcusable and piss poor patient care.


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## STXmedic (Dec 5, 2011)

Had a hyrocodone and morphine OD of unknown amount a few months back. He got 6mg naloxone pushed IV with only mild increase in respirations before we realized he also had 6 fentanyl patches on his butt 0_o. Tried to titrate the first bolus, but it ended up not even touching it. He ended up getting intubated...


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## Akulahawk (Dec 5, 2011)

emtvic17 said:


> give em 0.5 mg, just enough to get their respirations up, keep em happy sleeping, and avoid the projectile vomiting =), if respirations go below normal range, hit em with another 0.5mg. And if you hate the ER staff, push the rest to bring em back and leave em with some nice cleaning up to do.





n7lxi said:


> I hope you're kidding.


Something tells me "not kidding"...

There's no way I'd ever want to push 2 mg IV naloxone or even 0.5mg and then 1.5 mg later just to be spiteful. Doing that is absolutely hateful at best. I might do slow IV titration to effect and perhaps later deep IM of the balance for a much slower release of the drug, but NEVER would I even think about slamming in some naloxone just to make anyone's day that much worse...


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## jjesusfreak01 (Dec 9, 2011)

PoeticInjustice said:


> Had a hyrocodone and morphine OD of unknown amount a few months back. He got 6mg naloxone pushed IV with only mild increase in respirations before we realized he also had 6 fentanyl patches on his butt 0_o. Tried to titrate the first bolus, but it ended up not even touching it. He ended up getting intubated...



Didn't have enough Narcan on the truck for that guy, did you?


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## usafmedic45 (Dec 9, 2011)

> If you're pushing 2mg to be a hot shot or "punish" the PT for overdosing, you should have your hand slammed in a door. It's inexcusable and piss poor patient care.



I've never been prouder of you, young Padawan. LOL


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## STXmedic (Dec 9, 2011)

jjesusfreak01 said:


> Didn't have enough Narcan on the truck for that guy, did you?



Lol nope, not quite  We stopped at the 6mg; I think we had two more prefills left. The trucks on the west side here carry almost twice that


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## the_negro_puppy (Dec 10, 2011)

We have no choice but to give 1600 mcg of naloxone when we use it. That being said, i''ve never used it; opioid ODs are rare here. No huge heroin scene either.


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## NomadicMedic (Dec 10, 2011)

usafmedic45 said:


> I've never been prouder of you, young Padawan. LOL



Thanks. That made my day.


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## 46Young (Dec 10, 2011)

When deciding to use narcan, conventional thought is to titrate to respirations. Along with other clinical findings, a good way to do this is to use quantitative ETCO2 capnography. 

You can titrate to resps. If you give too much, they wake up too quickly, and risk vomiting or a withdrawal Sz, along with having to deal with a now violent combative pt. You can use small increments, such as 0.2-0.4 mg as mentioned earlier. Narcotics can outlast narcan, so capnography can be used to determine if the narcan is wearing off. 

It's also a good idea to use capnography for pts that receive narcotics or sedation as well.


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## 46Young (Dec 10, 2011)

To add to my last post, hypoventilation secondary to an opiate OD can present as a normal RR w/ a low tidal volume, not just a low RR alone.


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## Smash (Dec 11, 2011)

jgav07 said:


> I have noticed alot of reluctance to giving narcan in quite a few of the threads and I was just wondering the reasoning behind this. I don't know if I am missing something. I know in my MCA we use narcan all of the time and I have never seen nor heard of any problems from its use other than, vomiting and combativness. I'm a new medic and just want to be sure im getting it all down pat. Thanks.



The issue is not the use of narcan.  It is the use of narcan because the provider is too dumb, or lazy to be bothered working out what is wrong with the patient and forming an appropriate treatment plan.  I have seen comments on this site like "pinpoint pupils are enough, give the narcan" or words to that effect.  If the patient needs narcan, I give them some.  In fact, for over a decade we have been using a highly successful treat and release program, treating dozens, and at times hundreds of heroin overdoses across the service every week.  But not every opiate overdose needs narcan, and not every respiratory depressed patient is an opiate overdose.

So no, I'm not afraid of narcan.  I'm afraid of substandard clinicians practising cookbook medicine.


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## durac (Dec 11, 2011)

In my system the administration of Narcan is more respiratory driven ... usually dependant on SpO2 and capnography, not necessarily LOC.  0.4 mg - 2 mg starting bolus but i go up by 0.2 mg slow IVP increments.. if you've waken someone up too fast or seen someone else do it youll understand why


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## rmabrey (Dec 11, 2011)

The biggest problem locally is some doctors chew medics out for giving narcan, and other doctors chew them out for not giving it. So generally the choice is made dependent on what doctors are on duty that day. Sad but true 

Sent from my Desire HD using Tapatalk


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## themooingdawg (Dec 11, 2011)

our protocol uses either for hypoventilation or suspected narcotic od, so it can kind of go both ways, but i mean its one of those drugs that yeah, unless you're really thinking its narcotic od, pinpoint pupils, hx of opiate use, track marks, environment situations, then use it, but i would try and assess for other things first before putting in the narcan, unless it warrants immediate use


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## themooingdawg (Dec 11, 2011)

but ya, when i give it, i definitely titrate it to effect


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## bigdogems (Dec 18, 2011)

46Young said:


> When deciding to use narcan, conventional thought is to titrate to respirations. Along with other clinical findings, a good way to do this is to use quantitative ETCO2 capnography.
> 
> You can titrate to resps. If you give too much, they wake up too quickly, and risk vomiting or a withdrawal Sz, along with having to deal with a now violent combative pt. You can use small increments, such as 0.2-0.4 mg as mentioned earlier. Narcotics can outlast narcan, so capnography can be used to determine if the narcan is wearing off.
> 
> It's also a good idea to use capnography for pts that receive narcotics or sedation as well.



I thought I was going to be the first to bring up Capno
Of course you follow your local protocols but in general if someone has a good SPO2 and Capno is within normal range with good wave forms Im not going to give narcan even if they're unresponsive with pinpoint pupils. As brought up in previous posts there is the possibility of other drugs on board. There is no point in waking them up just to have to put them back down again with a benzo. As said I look at tidal volume as well. Not just rate. 

In a recent study they took several people and had them sit and read for a half hour while they read. The average rate was around 8/min. Not greatly scientific my any means just some food for thought


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## mycrofft (Dec 18, 2011)

*MICP, good one.*

Someone mentioned endogenous opioids as mood regulators. I was just reading Temple Grandin's book (Animals in Translation) and she cites studies where suppressing endorphins  in otherwise unaffected animals will cause them to become more aggressive. Maybe we potentiate "rage upon awakening" by slamming Narcan into someone whose endorphin balance is whack, causing them to swing the other way. Be kind of hard to study, I think.


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## MedicPatriot (Dec 18, 2011)

See, I always TRY to titrate but they always completely wake up even after .4mg slow. The only time I really give the full 2mg is if its IM or Nasal. I haven't used the nasal atomizer on a patient yet but at least I won't have to stick a heroin addict. I hear it works decent.

I have no fear of giving Narcan at all so I don't know why people say that. OTOH I don't give the old "cocktail" just bc someone is unconscious. I had a unconscious heroin addict today I didn't give Narcan and someone asked why not. Well his pupils were fine, RR fine, and maybe because he was unconscious due to a head injury and NOT from heroin? Lol.


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## usafmedic45 (Dec 18, 2011)

> Be kind of hard to study, I think.



Another reason I want to go take a dump on the grave of Sigmund Rascher and into the box containing the bones of Josef Mengele.


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## usalsfyre (Dec 18, 2011)

MedicPatriot said:


> See, I always TRY to titrate but they always completely wake up even after .4mg slow.


So give 0.2mgs. There's no one saying you can't give less than 0.4mgs. Or give it IM. Understanding the medication beyond a drug card is actually pretty essential to doing this job well.



MedicPatriot said:


> I have no fear of giving Narcan at all so I don't know why people say that.


Because other people have sufficient education and experince to know the bad things that can happen. The longer I'm a medic and the more I perform certain procedures the more they scare me. Doesn't mean I don't perform them, but a hefty dose of caution has been added.


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