Versed after Narcan for OD patients?

[Sally Jones]

What’s your opinion of giving Versed for possible combative behavior following Narcan administration that brought back respiratory drive?
Unresponsive patient, alcohol smell on patient, bloody new AC track mark, patient at known drug/ frequent 911 response location.

 

[mgr22]

Sally, I know this isn't an answer to your question, but was the Narcan titrated? Or is this all hypothetical?

 

[SpecialK]

I'd just not give them the naloxone.

It's much easier to put in an LMA and ventilate somebody who might have a stuffed blue noggin and let the hospital slowly wake them up where they have lots of light and personnel and resources than in the back of an ambulance, or worse, on their lounge floor.

 

[Sally Jones]

Narcan intranasal 2 mg given to unresponsive OD patient that had fresh track marks, alcohol smell at frequent 911 response location for similar calls. Not hypothetical.

 

[Sally Jones]

I'd just not give them the naloxone.

It's much easier to put in an LMA and ventilate somebody who might have a stuffed blue noggin and let the hospital slowly wake them up where they have lots of light and personnel and resources than in the back of an ambulance, or worse, on their lounge floor.

Yes I agree with you.

 

[Sally Jones]

Sally, I know this isn't an answer to your question, but was the Narcan titrated? Or is this all hypothetical?

Narcan intranasal 2 mg given to unresponsive OD patient that had fresh track marks, alcohol smell at frequent 911 response location for similar calls. Not hypothetical.

 

[mgr22]

Narcan intranasal 2 mg given to unresponsive OD patient that had fresh track marks, alcohol smell at frequent 911 response location for similar calls. Not hypothetical.

So, sounds like the combativeness was secondary to all-or-nothing, BLS-level dosing. I haven't been in that situation, but benzos have certainly been an option at the hospital for combativeness after excessive Narcan prehospitally.

 

[Peak]

I would have rather supported their airway and respirations that have given the narcan in the first place. I would have bagged, dropped an LMA, or just tubed them depending on their presentation and how far we are from the hospital. Depending on how they were found and what there clinical presentation is they may have earned themselves imaging that is now going to be almost impossible, IV access will be more difficult, and arterial sampling will be near unobtainable. To me narcan is something we start on borderline patients when we don't want to tube in the ED, but either way they are likely to earn themselves an admission. I can only remember giving narcan once in the field and it was on a little old lady who accidently took too many MS Cotins after her hip surgery.

If someone gave narcan prior to my arrival and we now have a combative patient, yes you can give versed but understand that narcan does have some effects on benzodiazepines. You could also consider ketamine or haldol depending on clinical presentation. In the ED if we needed them back down for procedures I would plan on giving 1-2 mg/kg IV or 5 mg/kg IM ketamine.

 

[Sally Jones]

So, sounds like the combativeness was secondary to all-or-nothing, BLS-level dosing. I haven't been in that situation, but benzos have certainly been an option at the hospital for combativeness after excessive Narcan prehospitally.

Good info. And Yes BLS agency gave Narcan.

 

[Sally Jones]

I would have rather supported their airway and respirations that have given the narcan in the first place. I would have bagged, dropped an LMA, or just tubed them depending on their presentation and how far we are from the hospital. Depending on how they were found and what there clinical presentation is they may have earned themselves imaging that is now going to be almost impossible, IV access will be more difficult, and arterial sampling will be near unobtainable. To me narcan is something we start on borderline patients when we don't want to tube in the ED, but either way they are likely to earn themselves an admission. I can only remember giving narcan once in the field and it was on a little old lady who accidently took too many MS Cotins after her hip surgery.

If someone gave narcan prior to my arrival and we now have a combative patient, yes you can give versed but understand that narcan does have some effects on benzodiazepines. You could also consider ketamine or haldol depending on clinical presentation. In the ED if we needed them back down for procedures I would plan on giving 1-2 mg/kg IV or 5 mg/kg IM ketamine.

Good info. Thanks!

 

[mgr22]

If someone gave narcan prior to my arrival and we now have a combative patient, yes you can give versed but understand that narcan does have some effects on benzodiazepines. You could also consider ketamine or haldol depending on clinical presentation. In the ED if we needed them back down for procedures I would plan on giving 1-2 mg/kg IV or 5 mg/kg IM ketamine.

Peak, I haven't heard of Narcan affecting benzos. Are we talking something anecdotal, or something evidence-based?

 

[Sally Jones]

Peak, I haven't heard of Narcan affecting benzos. Are we talking something anecdotal, or something evidence-based?

I have not heard of Narcan effecting benzo either.

 

[Peak]

@Sally Jones @mgr22

https://www.ncbi.nlm.nih.gov/pubmed/20573655

The effect is certainly not as great as with flumazenil, and the mechanism isn't fully understood, but narcan is known to have efficacy in treating benzos.

 

[mgr22]

@Sally Jones @mgr22

https://www.ncbi.nlm.nih.gov/pubmed/20573655

The effect is certainly not as great as with flumazenil, and the mechanism isn't fully understood, but narcan is known to have efficacy in treating benzos.

Thanks, Peak. I was unaware of that.

 

[Tigger]

@Sally Jones @mgr22

https://www.ncbi.nlm.nih.gov/pubmed/20573655

The effect is certainly not as great as with flumazenil, and the mechanism isn't fully understood, but narcan is known to have efficacy in treating benzos.

Huh, who knew. Not me.

I don't think I would have any issue giving some Versed (or Ativan) to this patient if it helped to facilitate their safe transport. We have the ability to manage their airway and not sedating and putting us at risk as a result is not worth the potential for mangeable respiratory compromise. As mentioned, Ketamine is also an option and lessens respiratory comprise risk for many.

 

[VFlutter]

Are you talking about giving it prophylacticly for "possible" combative behavior before the patient even arouses? If so, that is not really appropriate.

 

[medichopeful]

What’s your opinion of giving Versed for possible combative behavior following Narcan administration that brought back respiratory drive?
Unresponsive patient, alcohol smell on patient, bloody new AC track mark, patient at known drug/ frequent 911 response location.

If they're unresponsive, why are you giving them versed? Or was that the initial status?

Personally, if I had the option and HAD to re-sedate someone who has an opioid in their system, I would go with Ketamine. Once that narcan wears off, the benzo/opioid mix is pretty potent. After that would probably be Haldol. I would try to avoid any benzos, but would use them if I had to.

That being said, the best way to avoid this situation is to titrate narcan to respiratory drive, NOT consciousness.

 

[TXmed]

Reasons these patients are combative after narcan administration

1. They are hypoxic
2. They are hypercapnic
3. They have a sympathetic surge
4. Mixed use of drugs.

If you treated hypoxia and hypercapnia before giving narcan alot of it can be avoided.

 

[cprted]

Reasons these patients are combative after narcan administration

1. They are hypoxic
2. They are hypercapnic
3. They have a sympathetic surge
4. Mixed use of drugs.

If you treated hypoxia and hypercapnia before giving narcan alot of it can be avoided.

This can't be emphasized enough. Too many people are so fixated on giving the supposedly "miracle life saving drug" that they forget to appropriately oxygenate and ventilate these patients.

 

[StCEMT]

You can also just restrain your patient before giving anything and once they are awake and visibly calm, undo them. I know a few people prefer that route should they wake up. No messing with narcs and adding another drug to the mix.