Administration of Narcan for AMS

[MS Medic]

This came up in another thread and I want to answer it without derailing the original topic so I created this one.

Are people still giving Narcan to patients just to rule something out? Pupils are not pinpoint, respiratory drive clearly has not been depressed, and really nothing about this patient is making me think a narcotic overdose unless I am missing something...

While I don't blanket administer Narcan to all AMS, in the case of the original thread I would. If you administer Narcan and there aren't any opioids attached to the mu receptors of the CNS, then it will have no effect on the pt causing no down side to its administration. On the other hand, if the pt does have an opioid in system who symptoms might be masked, then there is benefit.

As you stated, the pt doesn't show signs of an opioid OD and I agreed. But the stated pt is significantly ill and there was an hour long transport consisting of primarily supportive care, so I would administer Narcan to "rule out" an opioid toxidrome.

 

[NomadicMedic]

That's just bad medicine.

 

[MS Medic]

Why do you say that?

 

[NomadicMedic]

Because narcan isn't even remotely indicated in the patient that is cited. And giving an opoid reversal agent to a patient simply because you're bored during an hour long transport and you don't know what else to do is bad medicine. That's why.

 

[MS Medic]

I never said anything about giving it because I was bored. That type of statement is comes close to hyperbole.

Based on the information available when I originally posted that, if all other treatment possibilities have been exhausted, your options are to simply sit there and look at the pt or try something that has a significant possibility of having no effect but will only have a positive effect if does have one. In that scenario, trying the long shot isn't bad medice.

 

[TXmed]

I don't necessarily agree with that. While an opiod OD might not be the main reason they're altered it could be adding to it. Such as septic patients on opiods or polyoverdoses.

I once randomly gave it for a benadryl OD (suicide attempt) in which there was no indication, but it woke him up and kept me from intubating him. Come to find out he took his prescription hydro that morning like he was supposed too and it along with the benadryl contributed to the AMS

 

[MS Medic]

I don't necessarily agree with that. While an opiod OD might not be the main reason they're altered it could be adding to it. Such as septic patients on opiods or polyoverdoses.

I once randomly gave it for a benadryl OD (suicide attempt) in which there was no indication, but it woke him up and kept me from intubating him. Come to find out he took his prescription hydro that morning like he was supposed too and it along with the benadryl contributed to the AMS

This is exactly the reasoning why I would give Narcan. I do realize it isn't likely an opioid, without the ability to run a tox screen, you can't absolutely rule it out. With that, Narcan should be considered as a later treatment possibility when everything else has been done.

 

[StCEMT]

If there is an off chance that there is benefit and no chance of hurting the patient, how would giving it be bad medicine? TX isn't the first person I've heard say they've tried it to rule something out and it actually helped. Seems like a rather simple way to cross something off your list and narrow things down.

 

[NomadicMedic]

Tell me why Narcan is indicated? Are you so concerned with her respiratory status that she's about to get tubed?

Is her respiration depressed? Are her pupils pinpoint? Is there any history of opoid use? Did you see any paraphernalia around? Is nana missing a fentanyl patch? Is this really presenting as an opiate overdose?

No. It reeks of a bleed or sepsis. (Or that other thing that tigger will mention later)

Sorry, drugs for the sake of "eh, I dunno what it can be so...why not try Narcan" seems like crap medicine to me.

But you do you.

 

[TXmed]

If it keeps them from buying a tube then yea. And to quote my medical director "first rule is do no harm, and that ain't gonna hurt them"

 

[cruiseforever]

If there is an off chance that there is benefit and no chance of hurting the patient, how would giving it be bad medicine? TX isn't the first person I've heard say they've tried it to rule something out and it actually helped. Seems like a rather simple way to cross something off your list and narrow things down.

That was the same thing we were told about using oxygen.

 

[Carlos Danger]

Narcan for a patient in whom an opioid OD is not suspected and who is breathing just fine? Sure, why not.

I would have given a couple mg's of atropine too. You know, just in case there is some occult cholinergic toxicity going on.

 

[jwk]

Narcan for a patient in whom an opioid OD is not suspected and who is breathing just fine? Sure, why not.

I would have given a couple mg's of atropine too. You know, just in case there is some occult cholinergic toxicity going on.

Thank you!

Duh. We administer medication for INDICATIONS, not LACK of indications. "It couldn't hurt" is not an indication.

 

[NomadicMedic]

Thank god. For a minute I was thinking the educated providers were actually going to agree with giving medications for the heck of it....

 

[TXmed]

It's not like you're giving it for every healthy person. It's just a last ditch effort before having to Intubate. It's worked several times for me but I guess to each his own

 

[MS Medic]

Fair enough. Mainly wanted to discuss it without throwing off the other thread. Task accomplished.

 

[Summit]

Ever see a chronic pain patient get narcan when they don't need it?

Come on most borderline opiate od (anything occult is borderline) can be solved with some bagging until they clear up unless outs it's mscontin or a patch which you can find and remove.

Profound od needs the narcan.

 

[gotbeerz001]

I'll give Narcan for S/S of opioid OD with respiratory depression. I generally will just drop an adjunct and use capnography to determine adequate ventilation. If they are unresponsive but otherwise stable, is a nice quiet ride to the ED.

 

[StCEMT]

That was the same thing we were told about using oxygen.

True. But physiologically each makes sense. Narcan competes for receptor sites, but isn't shown (not that I am aware at least) to produce any effects once it binds to the receptors in the absence of an opiate. It's just there. While I only have a basic understanding of o2 toxicity, when the radicals come into contact with another cell, we know it causes damage. Higher PO2=More radicals=more damage to cells.

That and one of the indications in my book was coma/AMS of unknown origin. I will look up the exact wording when I get home tonight. If I don't know the origin of a pt's AMS, by what I have listed it is indicated. Other things I see might sway what I think one way or another, but either way, I don't see how it'd hurt to keep the idea in the back of your mind when going over things even if you don't use it. This is not the first time I've seen someone say they went out on a limb and it helped. But I am still learnin, so what the hell do I know, wouldn't be the first time I've been wrong.

 

[SandpitMedic]

Suspected opioids, yes.
Prior to intubation, yes.

Just because, no.