# Naloxone routes, which and why?



## ThisIsTheLastTime (Mar 28, 2016)

Hey there guys, I was hoping to bounce a question off yall. There is a lot of discussion in various threads about IM vs IN naloxone, but it's mostly brief and mentioned in relation to a more main point. I haven't seen any threads specifically comparing the two, so what is your experience and preference, and why?


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## NomadicMedic (Mar 28, 2016)

Snout. No sharps. Works great.


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## Tigger (Mar 28, 2016)

Usually just IV. If they are really out we probably need a line anyway, might as well do that while they aren't moving around. We finally purchased atomizers so I am curious to try them.


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## NomadicMedic (Mar 28, 2016)

Tigger said:


> Usually just IV. If they are really out we probably need a line anyway, might as well do that while they aren't moving around. We finally purchased atomizers so I am curious to try them.



Curious, why do they need a line if they're "really out"? They really just need Narcan, and if you can do it without sharps, isn't that a better solution? I haven't given IV Narcan in ages.


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## Tigger (Mar 28, 2016)

DEmedic said:


> Curious, why do they need a line if they're "really out"? They really just need Narcan, and if you can do it without sharps, isn't that a better solution? I haven't given IV Narcan in ages.


The prevailing line of thinking is a need (or potential) for airway management indicates a need for IV access. I am not sure where that came from. Often that is the case, but certainly not always. Also several of my partners believe that opiate overdose = severe hypotension. 

Nonetheless, if the patient requires an IV, I'd prefer to do that while the patient is obtunded instead of *potentially* agitated.


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## NomadicMedic (Mar 29, 2016)

Okay, fair enough. I believe in building yourself a safety net, but a simple, obvious prehospital opiate OD, at least for me, is a nose full of Narcan and a ride to the ED.

If, after 2mg of Narcan, the patient remained obtunded and exhibited respiratory depression to the point where I needed to support it, they're going to buy a tube.


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## phideux (Mar 29, 2016)

I've only given Narcan IV. I pretty much start at around 0.5mg, push slow, and titrate to effect, just enough to get that respiratory drive up.  Pretty hard to titrate IM or with a nasal atomizer. I don't like waking the sleeping junkies up all the way.


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## Inspir (Mar 29, 2016)

Straight from our protocols

"The efficacy of IM naloxone is such that it is the preferred route of administration"

We can also do IV or IO


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## ThisIsTheLastTime (Mar 29, 2016)

Inspir said:


> Straight from our protocols
> 
> "The efficacy of IM naloxone is such that it is the preferred route of administration"
> 
> We can also do IV or IO



interesting stuff. seems like there is a disconnect between protocol and practice


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## ThisIsTheLastTime (Mar 29, 2016)

phideux said:


> I've only given Narcan IV. I pretty much start at around 0.5mg, push slow, and titrate to effect, just enough to get that respiratory drive up.  Pretty hard to titrate IM or with a nasal atomizer. I don't like waking the sleeping junkies up all the way.



right right. no need for a 0-60 i suppose. you worry at all about increased hypoxia in titrating slowly?


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## TransportJockey (Mar 29, 2016)

IV here, titrated to respiratory effort. If I can get that up, but they stay sleeping, I'm ok with that.


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## phideux (Mar 29, 2016)

ThisIsTheLastTime said:


> right right. no need for a 0-60 i suppose. you worry at all about increased hypoxia in titrating slowly?



No worry, assisted ventilation with a BVM and O2 while getting a line and pushing it.


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## chaz90 (Mar 29, 2016)

My preference is 1 mg IN off the bat then begin looking for an IV. Typically by the time I have an IV up and running they have either had some improvement in their respiratory status and we can move on, or they haven't and I can administer an additional 0.5 mg IV. I don't really use IM that often for whatever reason.


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## STXmedic (Mar 29, 2016)

2mg IM, typically chased with another 2mg IM after the refusal. I've had a lot of variable results with IN administration, so I just stick with the slightly slower but more reliable IM route.


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## COmedic17 (Mar 29, 2016)

Depends on the situation. 

There's a big heroin problem in the city where I work. There has been times people have wrecked their vehicles while driving..one instance, a person had been shooting up, while driving, and the tourniquet was still on their arm, needle by them, etc. At this point, I obtain an IV because it is a trauma as well as a probable OD. 

In somebody with borderline vitals,  I typically do IM..slower onset, less likely to get punched in the face before my 5 minute transfer to hospital.

If someone is completely unstable, I will give IN first to get it in their system as quickly as possible. If they don't come around relatively quickly, I will follow with IV or IM. 

If all vitals are stable and breathing adequately, I just provide supportive care and withhold Narcan and let the ER decide if they want to give it or let the party come around on their own. I typically try to avoid throw downs in the back of the truck.


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## ThisIsTheLastTime (Mar 29, 2016)

COmedic17 said:


> Depends on the situation.
> 
> There's a big heroin problem in the city where I work. There has been times people have wrecked their vehicles while driving..one instance, a person had been shooting up, while driving, and the tourniquet was still on their arm, needle by them, etc. At this point, I obtain an IV because it is a trauma as well as a probable OD.
> 
> ...






STXmedic said:


> 2mg IM, typically chased with another 2mg IM after the refusal. I've had a lot of variable results with IN administration, so I just stick with the slightly slower but more reliable IM route.




so IN mainly for ease of use? have you started using the new single shot narcan or still amp and atomizer? i feel like there is evidence everywhere for IM over IN but people still choose IN regularly. mostly to avoid needle sticks?


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## STXmedic (Mar 29, 2016)

We use the 2mg prefills with luer lock. For the longest time, the prefills came with an affixed needle- we'd have to pop out the plunger and draw it up in another syringe if we wanted to use the MAD.

Yeah, the biggest reason I've heard is the lack of a needle with the MAD. I prefer the consistent and predictable absorption, so I just don't stab myself... The same goes for versed with seizures or ketamine/versed for the combative patients.


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## COmedic17 (Mar 29, 2016)

ThisIsTheLastTime said:


> so IN mainly for ease of use? have you started using the new single shot narcan or still amp and atomizer? i feel like there is evidence everywhere for IM over IN but people still choose IN regularly. mostly to avoid needle sticks?


I went through each senario and why I would  use each route. IN if they need it ASAP because it's already set up, quicker admin, then follow with IM or IV. Give them something to work with while I prep everything else.


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## ThisIsTheLastTime (Mar 29, 2016)

STXmedic said:


> We use the 2mg prefills with luer lock. For the longest time, the prefills came with an affixed needle- we'd have to pop out the plunger and draw it up in another syringe if we wanted to use the MAD.
> 
> Yeah, the biggest reason I've heard is the lack of a needle with the MAD. I prefer the consistent and predictable absorption, so I just don't stab myself... The same goes for versed with seizures or ketamine/versed for the combative patients.





COmedic17 said:


> I went through each senario and why I would  use each route. IN if they need it ASAP because it's already set up, quicker admin, then follow with IM or IV. Give them something to work with while I prep everything else.



ok cool, so IM is consistent and predictable and reliable, IN is like using mouthwash when you need to get out of the house, brush your teeth later kind of thing. am i starting to get it?


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## STXmedic (Mar 29, 2016)

Not sure I follow your analogy. When the MAD works as advertised, it's fast and effective. In my experience, it often doesn't work as advertised though. Incorrect technique, excessive mucous, and poor mucous membrane circulation can all affect its absorption. Some people still swear by it as their go-to device. I'm just impatient and don't like waiting around to see if it's going to kick in over some unknown amount of time before I re-dose, when I know the IM would've already kicked in. Use it a bit and form your own opinion. I haven't seen any good evidence stating its absolutely better or worse.


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## COmedic17 (Mar 29, 2016)

ThisIsTheLastTime said:


> ok cool, so IM is consistent and predictable and reliable, IN is like using mouthwash when you need to get out of the house, brush your teeth later kind of thing. am i starting to get it?


sort of. 

IN is a " my patient has no respiratory drive, is a transient outside in the cold,  wearing 8 layers of clothing meaning several layers will have to be removed before IM or IV is even a possibility, so IN is the fastest route, and I will establish a more reliable route when I am able able" kind of thing. 

It's hard to put a blanket term on the "best route" when it can be situational.


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## NomadicMedic (Mar 29, 2016)

Or, IN works... so let's do the least invasive procedure.


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## STXmedic (Mar 29, 2016)

DEmedic said:


> Or, IN works... so let's do the least invasive procedure.


Except when it doesn't... I've given it more than its fair opportunity to prove me wrong. At my last station, I literally had at least one heroin OD per shift. I lost count of how many times IN did not work. IM breaks the skin, but how honestly concerned are you to cause major problems with an IM injection? Use a little alcohol and you'll be fine. My two year old just got three IM injections in the same doctors visit. I'm not all that concerned.


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## ThisIsTheLastTime (Mar 29, 2016)

STXmedic said:


> Except when it doesn't... I've given it more than its fair opportunity to prove me wrong. At my last station, I literally had at least one heroin OD per shift. I lost count of how many times IN did not work. IM breaks the skin, but how honestly concerned are you to cause major problems with an IM injection? Use a little alcohol and you'll be fine. My two year old just got three IM injections in the same doctors visit. I'm not all that concerned.



wow thats powerful. i was just talking to a medic, and his thoughts are that there are too many variables with IN, like if they have a history of snorting drugs or if theyve had their nose cauterized IN can be pretty ineffective. sounds like this was your experience or something like it? anyone else have thoughts on this?


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## COmedic17 (Mar 29, 2016)

ThisIsTheLastTime said:


> wow thats powerful. i was just talking to a medic, and his thoughts are that there are too many variables with IN, like if they have a history of snorting drugs or if theyve had their nose cauterized IN can be pretty ineffective. sounds like this was your experience or something like it? anyone else have thoughts on this?


The biggest problem I see with it is if it runs out of the nostrils..usually if someone is fairly congested.

Even if it doesn't immediately get absorbed from previous nasal trauma or what not, it's going to eventually get absorbed as long as it stays in the body. Maybe not as fast as other routes, but it will still get into the system fairly quickly.


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## NomadicMedic (Mar 29, 2016)

I've never had IN Narcan not work. Anecdotally, of course.


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## Tigger (Mar 29, 2016)

I've never tried nor seen IM used, and now that we have safety needles (seriously....) I'd like to try it.


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## k9Dog (Mar 30, 2016)

IN and IM take 2-5 minutes in my experience. IV is immediate of course. IN is easiest, and doesn't require you sticking a needle in someone who likely has hep c or HIV. They all work, however. If the guy is completely apneic, I would have partner bag him and give it IV. If he's unresponsive but still has some respiratory effort, IN.


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## Smitty213 (Apr 1, 2016)

I am a huge fan of IM; a senior Medic I had the fortune to work with taught me the value of it about two years ago. IM metabolizes a little slower for a smoother, easier wake-up, it doesn't seem to "wear out" as fast as IN, and you don't have to worry about getting the line in that junkie with veins that are trashed. While not as immediate as IV, it only takes about a minute or so to start working, which is not that much time to assist ventilations for if you take into account total time to set up the line.


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## COmedic17 (Apr 1, 2016)

Smitty213 said:


> I am a huge fan of IM; a senior Medic I had the fortune to work with taught me the value of it about two years ago. IM metabolizes a little slower for a smoother, easier wake-up, it doesn't seem to "wear out" as fast as IN, and you don't have to worry about getting the line in that junkie with veins that are trashed. While not as immediate as IV, it only takes about a minute or so to start working, which is not that much time to assist ventilations for if you take into account total time to set up the line.


I have never seen IM anything have a profound effect in a minute or less.


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## Smitty213 (Apr 1, 2016)

COmedic17 said:


> I have never seen IM anything have a profound effect in a minute or less.


It's not profound, which is what makes it nice. I'd say it takes 5 minutes for full effect, but I usually would estimate seeing some minor changes after the first minute or so.


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## TattooedNay (Apr 6, 2016)

The cops in my area are very well trained first responders. If they haven't given IN prior to our arrival I will usually start out with 0.5 IN. It's case by case... Heroin is HUGE around here and unfortunately it's easy to see when the streets are "being cleaned". If there is a bad batch going around maybe 1mg IN. and secure a line. I really prefer to not be covered in vomit and have an irate pt. in the back with me. Transport times are pretty quick so just enough to keep them breathing works for me.


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## TXmed (Apr 6, 2016)

Chicago FD did a study where they gave narcan via nebulizer. I have done it several times and it works great.


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## STXmedic (Apr 6, 2016)

Years ago it used to be standard practice here to give intralingual Narcan. Apparently it worked fairly well- never saw it myself.


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## NPO (May 22, 2016)

Our protocols allow IV/IM/IO/IN with no preference towards a particular route. I've only given it IV, but fully willing to give it IN if I have any inclination to believe the patient will be, or is, agitated. I also generally give small doses, just to keep my patient alive and breathing well on their own. I generally leave them still a little sedated for safety and ease. 

For semantics, the FDA recommends the IN route becuase its needle-less. 

Our protocols also mention considering an IM dose following IV doses to give a prolonged effect to prevent relapse.

Also, if you're interested in some fun party trivia, look up IV drip Narcan for treatment of sepsis.


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## STXmedic (May 22, 2016)

Funny that this thread popped up again today. Our third run of the day was a heroin OD. Basics in fire can give IN (only) Narcan, so my partner let one of the basics give 2mg IN when we got there. Again, IN didn't work after a more than reasonable amount of time. 2mg IM worked as expected. It certainly could've been the patient simply required considerably more than 2mg, but it also follows the trend I (anecdotally) see of IN being unreliable and marginally effective.


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## JIP00 (Jun 10, 2016)

I too have never had IN not be effective. What is a reasonable amount of time? If you can ventilate without difficulty and keep your Sp02 up what is the rush to intubate or blast someone with IV Narcan? If it's taking them that long to wake up with IN Narcan it's probably polysubstance.


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## NPO (Aug 12, 2016)

I gave narcan IN to try it. Meh.


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## ALS AXE (Aug 27, 2016)

I find that administering naloxone IN with 1-2 mg split between nares can get things moving while you are establishing a IV. Then I reassess and if I elect to administer more, then I may do so through my IV access. But it all depends on what you try ( with in your protocols ) and what you find works best in your system.


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