Administration of Narcan for AMS

[TXmed]

Alright, the socioeconomic question was meant to elicit discussion, no reason to start posturing.

I do believe we are being a little bit too "all or nothing" with the stance that respiratory depression is the end-all, be-all decision maker for the administration of narcan. Altered LOC, in and of itself, can have its own set of issues and potential necessity for reversal. Is the patient so far unconscious that self maintenance of their airway may become an issue? Is there a potential for opiate use and/or abuse? Is the administration of narcan better for these patients than securing their airway? If the above answers are true, then why does a respiratory rate of 12 drive your decision making process?

None of the questions I asked have absolute answers, and neither should your approach to your patient. Certainly unconsciousness with respiratory depression and friends saying "he used heroin" will bring me to narcan more quickly, but an absence of respiratory depression certainly doesn't take narcan completely off the table, in my book.

Great point !!

So I have a question now. Would anybody be comfortable transportating an altered patient with no gag reflex ? Say GCS <8? Regardless of respiratory rate, without intervention with narcan or ET tube ?

 

[DesertMedic66]

Great point !!

So I have a question now. Would anybody be comfortable transportating an altered patient with no gag reflex ? Say GCS <8? Regardless of respiratory rate, without intervention with narcan or ET tube ?

My protocols are extremely limited and often I am given no other choice but to do this.

 

[Carlos Danger]

Great point !!

So I have a question now. Would anybody be comfortable transportating an altered patient with no gag reflex ? Say GCS <8? Regardless of respiratory rate, without intervention with narcan or ET tube ?

It depends, of course.

Unresponsiveness is not an emergency in itself.

How would you know they had no gag reflex, in this hypothetical scenario?

 

[Carlos Danger]

I do believe we are being a little bit too "all or nothing" with the stance that respiratory depression is the end-all, be-all decision maker for the administration of narcan. Altered LOC, in and of itself, can have its own set of issues and potential necessity for reversal. Is the patient so far unconscious that self maintenance of their airway may become an issue? Is there a potential for opiate use and/or abuse? Is the administration of narcan better for these patients than securing their airway? If the above answers are true, then why does a respiratory rate of 12 drive your decision making process?

Not really.

Altered LOC is not an emergency in and of itself, despite what we've been brainwashed into believing.

Anyone who is narcotized to the point that they have obvious airway compromise and are unresponsive to painful stimulus is almost certainly going to have noticeably depressed ventilatory drive.

To put it another way, someone who is breathing just fine is highly unlikely to be narcotized, and therefore highly unlikely to respond favorably to narcan.

 

[TXmed]

Not really.

Altered LOC is not an emergency in and of itself, despite what we've been brainwashed into believing.

Anyone who is narcotized to the point that they have obvious airway compromise and are unresponsive to painful stimulus is almost certainly going to have noticeably depressed ventilatory drive.

To put it another way, someone who is breathing just fine is highly unlikely to be narcotized, and therefore highly unlikely to respond favorably to narcan.

Well my thinking is less of a straight forward OD and more of a polypharmacy mixing benzo, narcotics, stimulants, everybody mix's alcohol with everything or having a mix of prescribed medications and medical problems such as sepsis.

There are alot of people with no or very little gag reflex and if you mix that with extensive alcohol, Xanax or sleep medication (which is becoming more popular) then you will get an unarrousable patient with intact respiratory drive, and the ability to quickly aspirate. This are patients that are candidates to get intubated in an ER because the doctor doesn't feel comfortable leaving them in a room by themselves.

 

[NomadicMedic]

Right, but if you transport them in high Fowlers and are attentive, there is little chance of them aspirating.

However, if it was indeed true that the patient had no gag reflex and a GCS of less than 8, they would wind up getting intubated as a matter of course. They wouldn't necessarily receive Narcan though.

 

[ERDoc]

Great point !!

So I have a question now. Would anybody be comfortable transportating an altered patient with no gag reflex ? Say GCS <8? Regardless of respiratory rate, without intervention with narcan or ET tube ?

If they cannot protect their airway for whatever reason, then we need to. That doesn't mean they need a narcan trial before the tube unless there is a reason to believe there are opiates involved. If it is a polypharmacy OD, then I would much rather tube the pt and let it all work out of their system than reverse the opiates and have another issue to deal with.

I'm amazed that there are still coma cocktail or coma pseudo-cocktail protocols out there.

 

[TXmed]

Right, but if you transport them in high Fowlers and are attentive, there is little chance of them aspirating.

However, if it was indeed true that the patient had no gag reflex and a GCS of less than 8, they would probably wind up getting intubated as a matter of course. They wouldn't necessarily receive Narcan though.

Ok, I can get behind that. But as a provider I always try to keep my patients from getting a tube if I can help it. Not really with a coma cocktail or anything like that.

 

[Seirende]

That's a very simplistic assumption of patient state. Image opioid countering poly pharmacy of the stimulant variety? Or chronic pain state now out of control!

This is the part that EMS doesn't get to see. Doing something in the ambulance can have huge consequences downstream. There was recently a case here where EMS picked up a pt on chronic, high dose opiates from a nursing home (we won't even get into that part) who was altered. The pt was not given any additional meds over her normal meds and did not have access to anything she wasn't prescribed. This crew hit this poor 60 something woman with 4mg IV narcan. After they drop her off she develops horrible withdrawal (heart rate in the 150s, RR in the 30s, agitated, combative, pupils were huge) and she was no more lucid than she was when she arrived. She was given massive amounts of dilaudid and ativan. She ended up being intubated when she started to tire. The admitting service tried putting a subclavian line in and dropped her lung. She then required a chest tube. So, this woman who was not a narcotic overdose was given a medication than doesn't do any harm because, "hey, it couldn't hurt," and ended up in opiate withdrawal, intubated and with a central line and chest tube, none of which probably would have been needed in the first place if the narcan was not given.

Never say a medication doesn't have a downside. They all do and the effects can be disastrous.

I'm still at the point where the majority of my thinking is based on what I learned in initial education. The two things that were drilled into my head about Narcan were that you only give enough to get the patient breathing, because it's dangerous to wake them up, and secondly, that if it's a mixed OD such as heroin+cocaine, the patient can go into cardiac arrest if you take away the opioid that is opposing the stimulant. I think some of my podcasting MD idols would call that "a clean kill." Lesson being, only give Narcan for respiratory failure or arrest, and only enough to restore the respiratory drive.

Withdrawal in chronic pain control patients was not something that I remember being taught or thinking of myself, so thank you guys for that.​

 

[FiremanMike]

Not really.

Altered LOC is not an emergency in and of itself, despite what we've been brainwashed into believing.

Anyone who is narcotized to the point that they have obvious airway compromise and are unresponsive to painful stimulus is almost certainly going to have noticeably depressed ventilatory drive.

To put it another way, someone who is breathing just fine is highly unlikely to be narcotized, and therefore highly unlikely to respond favorably to narcan.

I'll start turfing all of my altered mental status patient's and tell the family "Remi from the internet says this isn't an emergency"..

All joking aside, you are insistent that narcan needs to be always off the table unless the respiratory rate is below a certain threshold and I'm insistent that I never speak in absolutes. Don't assume that I give out narcan indiscriminately, but it remains a part of my potential arsenal at all times with ALOC patients.

 

[SixEightWhiskey]

correct me if i missed it, but no one has brought up that narcan is not necessarily a benign drug. Besides withdrawal seizures and untoward affects based on size of the dose given vs. the dose of the opiate still in the system, people can have unknown hypersensitivities to it like any other medication. Adverse reactions, per the manufacturer, can include VF and cardiac arrest. I've personally seen someone go into pulmonary edema/ARDS s/p narcan administration who required emergent RSI, and ultimately ICU care.

Anyone else have thoughts on this?

 

[COmedic17]

I don't give narcan -even with confirmed opioid use- unless they are unstable.

If they are breathing, have a normal BP, etc I just transport them in. It's not worth possibly putting someone into seizure, getting projectile vomited on, or getting punched in the face if the patient is completely stable.

There's even some repeat offenders that I restrain their arms prior to giving narcan, because from past experiences, I know they are going to be out for blood when they come around.

Also food for thought- if you're going to push narcan for a depressed resp drive on an opioid OD, push the narcan BEFORE you drop the tube....I know someone who tubed first... It did not turn out well.

 

[medichopeful]

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.

There's actually some literature out there about narcan use in septic shock.

http://dailymed.nlm.nih.gov/dailymed/drugInfo.cfm?setid=76f7eee1-d524-43a4-a868-ffa9f29638a6

http://www.cochrane.org/CD004443/IN...re-needed-to-show-whether-this-reduces-deaths

 

[STXmedic]

Narcan, because I don't know what else to do...

Coming from the guy who regularly "treats and streets" heroin users... Lol

 

[wilderness911]

correct me if i missed it, but no one has brought up that narcan is not necessarily a benign drug. Besides withdrawal seizures and untoward affects based on size of the dose given vs. the dose of the opiate still in the system, people can have unknown hypersensitivities to it like any other medication. Adverse reactions, per the manufacturer, can include VF and cardiac arrest. I've personally seen someone go into pulmonary edema/ARDS s/p narcan administration who required emergent RSI, and ultimately ICU care.

Anyone else have thoughts on this?

Fascinating stuff, 68W. Thanks for sharing. I had never heard of an actual adverse reaction to narcan before, and I appreciate you taking the time to share that.

 

[wilderness911]

Heh...my first thought was "Why the hell would you push narcan for acute mountain sickness!?"

Time to pound some coffee and activate the brain.

 

[wilderness911]

If they are breathing, have a normal BP, etc I just transport them in. It's not worth possibly putting someone into seizure, getting projectile vomited on, or getting punched in the face if the patient is completely stable.

Right there with you buddy. And when I do push it, I like to go nice and slow - just enough to bring back the respiratory drive, not enough to bring back the attitude. Don't always succeed in shooting the moon on that one, but when I have it has resulted in an all around more pleasant experience for all parties. I have never understood when medics slam a full bolus of narcan - it's a recipe for trouble.

Also, I have yet to push narcan for any patient without confidence they were ODing on opiates. Pupillary miosis, diaphoretic skin, apnea or inadequate ventilations always provide a strong tell. I also shine a light up the nostrils to look for residue indicating insufflation and do a quick check in the usual IV drug user sites for additional indications. Usually there are plenty of signs that an opiate is involved, and it is rare (in my experience at least) that a patient manages to OD on oral opiates. Pro tip: blue smurf boogers result from roxicodone insufflation and are a pretty easy way to figure out what happened, if that was the flavor of the day. In a number of my patients roxicodone has been the culprit, as it is cheap, widely available, instant release, and free from any acetaminophen to deter abuse.

 

[ExpatMedic0]

Who here is old enough to remember the coma cocktail? It use to be a thing... Then evidence base medicine came along and took away all the fun.

 

[NomadicMedic]

Who here is old enough to remember the coma cocktail? It use to be a thing... Then evidence base medicine came along and took away all the fun.

Sure. I also remember using EOAs, a lifePak 5 and a jaw screw.

I don't miss any of that "fun".

 

[wilderness911]

Sure. I also remember using EOAs, a lifePak 5 and a jaw screw.

I don't miss any of that "fun".

What's a jaw screw?