Routine Narcan Use

[mttbdtd]

I've been working in the field as a medic for about 11 months now. I just wanted to get a feel for how others operate. How many other providers give Narcan routinely to unresponsive/altered patients regardless of s/s of opiate use? I personally have had a few instances where I come across an unresponsive drunk with bottle in hand, pupils are 4+ and reactive not sluggish, resp rate/drive not depressed, vital signs stable. First question out of some people's mouths is "did you give Narcan?" A legitimate question and I'm not arguing. Curious to hear more experienced people weigh in.

 

[DesertMedic66]

No S/S of a narcotic OD they will not receive Narcan from me. Narcotics are not a huge issue out here and in over a year and a half I have only given Narcan maybe 5 times.

 

[mttbdtd]

I noticed I didn't answer my own question. No s/s=no Narcan for me.

 

[Summit]

pupils are 4+ and reactive not sluggish, resp rate/drive not depressed, vital signs stable.

This is an extremely good reason not to give narcan, even if they don't have a handle of gin next to them

 

[VentMonkey]

How many other providers give Narcan routinely to unresponsive/altered patients regardless of s/s of opiate use?

This has been brought up a few times on this forum, and the general consensus seems to be along the lines of clear cut s/s of an opiate OD only (pinpoint pupils, decreased respiratory pattern, known opiate intake history, etc.); this is my only indication for it.

First question out of some people's mouths is "did you give Narcan?" A legitimate question and I'm not arguing. Curious to hear more experienced people weigh in.

What part of this question seems legitamite to you, personally? I am genuinely curious. An unresponsive drunk with bottle in hand would seem to be a recipe for disaster coupled with Narcan administration. This is what separates a "thinking paramedic" from a "cookbook" paramedic.

I'm not digging at you, op. I'm trying to get you to think what would be a good reason to give a person who already has the potential to vomit all over themselves, you, your partner, and/ or the back of your ambulance a medication that may very well potentiate this, particularly while they sit facing backwards driving to the ED in a presumably bumpy vehicle...

 

[mttbdtd]

I don't believe in just throwing meds at things in a "blanket" sense. I don't know who lurks in these forums so I can at the post rather timidly. I've been hit in QA and by doctors. Without breaking down entire calls. QA for a TCA overdose. Reason is that person gives Narcan for every pill overdose. Told by a doc rather forcefully when I brought unresponsive drunk that pupil response has nothing to do with opiates being onboard. Narcan was promptly pushed in the ER with no response. I guess I should have come out swinging from the beginning. I think it is stupid medicine to have an I ALWAYS do (insert thing here) process. I say the question is legitimate when peers hear you had an unresponsive and they weren't there and ask that.

 

[StCEMT]

I didn't even give the last heroin user I picked up Narcan, I don't think I would be worried about it unless there is respiratory depression. Although it is technically in my protocols for coma of unknown origin.

 

[mttbdtd]

I kind of feel people are trying to cram me into a cookbook process. I am always able to defend myself well but it's kinda getting old fast.

 

[VentMonkey]

I kind of feel people are trying to cram me into a cookbook process. I am always able to defend myself well but it's kinda getting old fast.

Where do you work? If you don't want to share it on the forum publicly, feel free to PM me.

 

[VentMonkey]

I didn't even give the last heroin user I picked up Narcan, I don't think I would be worried about it unless there is respiratory depression. Although it is technically in my protocols for coma of unknown origin.

Same here. We get those that are groggy and clearly high as a kite, though our protocols do call for us to use our better judgment.

So! No poking the bear...

 

[EpiEMS]

The only "always" in my book is "always getting a good history and physical exam."

So, no, no naloxone unless signs and symptoms of opioid overdose with associated respiratory depression.

 

[NPO]

I will occasionally give it, only because I've seen some patient's without pinpoint pupils respond to it, so my personal criteria for S/S of narcosis is a little more on the respiratory side.

I recently took a mid 30s female on a 911 call. She was snoring on scene and painful stimuli only got some minor movement from her right arm. I gave 2mg IV enroute to the hospital, just as a tool to rule out narcotics.

Turned out she had a rather large brain bleed.

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[VentMonkey]

I will occasionally give it, only because I've seen some patient's without pinpoint pupils respond to it, so my personal criteria for S/S of narcosis is a little more on the respiratory side.

I recently took a mid 30s female on a 911 call. She was snoring on scene and painful stimuli only got some minor movement from her right arm. I gave 2mg IV enroute to the hospital, just as a tool to rule out narcotics.

Turned out she had a rather large brain bleed.

Sent from my SM-G935T using Tapatalk

http://emtlife.com/threads/the-drug-induced-ich.44619/

Perhaps small push dose boluses. I usually do not give the whole 2 mg, if again, they meet opiate OD criteria to me.

If by the first mg there's no response, you should probably be thinking elsewhere for a differential work-up.

 

[phideux]

OP, no respiratory depression, 4mm+ reactive pupils, vitals WNLs, no reason for Narcan.

VentMonkey, with Narcan I use your approach, I like to titrate to effect. I'll push 0.5mg and give it a minute or 2, then push another 0.5mg if necessary, bring them up slowly. Less cleaning puke out of the back of the ambulance and less fighting with the pill-head whose high you just blew

 

[NPO]

http://emtlife.com/threads/the-drug-induced-ich.44619/

Perhaps small push dose boluses. I usually do not give the whole 2 mg, if again, they meet opiate OD criteria to me.

If by the first mg there's no response, you should probably be thinking elsewhere for a differential work-up.

Agreed. I gave it as 2 x 1mg boluses. Only because she would occasionally respond, and I didn't know if that was an improvement from the no response prior, or just coincidence. I had in my mind, the memo we got from County EMS

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[VentMonkey]

Agreed. I gave it as 2 x 1mg boluses. Only because she would occasionally respond, and I didn't know if that was an improvement from the no response prior, or just coincidence. I had in my mind, the memo we got from County EMS

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The Carfentanil memo? That drug should present with definite signs of an opioid OD if that's the case; it's essentially a hybrid synthetic opioid that may not even respond to Narcan (definitely indicated) with our short metro ETA's.

As far as the 1 mg x 2? I do 0.5 mg titrated to effective breathing (improvement). We don't need to give the whole lot almost all of the time when giving it, which TMK is also written in our county protocols. All good though, live and learn.

On another note, hopefully they can get the AMLS course up and running again. I highly recommend for any new (generalizing) paramedic that does not have it. Just bases on the differentials they throw at you alone helps build on critical thinking skills in the field.

Just my $0.02 though.

 

[StCEMT]

The Carfentanil memo? That drug should present with definite signs of an opioid OD if that's the case; it's essentially a hybrid synthetic opioid that may not even respond to Narcan (definitely indicated) with our short metro ETA's.

As far as the 1 mg x 2? I do 0.5 mg titrated to effective breathing (improvement). We don't need to give the whole lot almost all of the time when giving it, which TMK is also written in our county protocols. All good though, live and learn.

On another note, hopefully they can get the AMLS course up and running again. I highly recommend for any new (generalizing) paramedic that does not have it. Just bases on the differentials they throw at you alone helps build on critical thinking skills in the field.

Just my $0.02 though.

0.5mg titrated worked beautifully last night for me.

And I agree on AMLS, it was one of my favorite ones to take. The scenarios they threw at us were definitely better.

 

[Carlos Danger]

I wonder if doxapram would have any utility in conjunction with naloxone for OD's of these exotic synthetic opioids.

Even much larger-than normal doses of naloxone often don't work, per many reports. What if we sensitized the chemoreceptors with doxapram in addition to using naloxone to reverse as much of the mu2 binding as possible?

What do you think, @Nova1300? I've only read about doxapram; never used it.

 

[VentMonkey]

I wonder if doxapram would have any utility in conjunction with naloxone for OD's of these exotic synthetic opioids.

Even much larger-than normal doses of naloxone often don't work, per many reports. What if we sensitized the chemoreceptors with doxapram in addition to using naloxone to reverse as much of the mu2 binding as possible?

What do you think, @Nova1300? I've only read about it doxapram.

I admittedly am unfamiliar with this reversal agent, therefore, for any others unfamiliar as well definitely a good read. Thanks again, @Remi.

http://m.lan.sagepub.com/content/23/2/147.short

 

[Carlos Danger]

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173639/