Heres one for you guys!

[abckidsmom]

Traumatic extubation, not just for demented ICU patients anymore .

Back in the day, we had some guys go on a known narc OD, intubate the pt, and then put the narcan down the tube. 2 mg.

It was not pretty. Not pretty at all.

 

[Handsome Robb]

What issues with intubation does narcan cause, I'm curious, never heard of this happening?

Post intubation care ie sedation/analgesia.

Sorry for the delayed reply guys, its been a crazy day. This call happened probably a month ago, but i'll give it ago. Next time i'll try to include more info on the OP, first time putting one of these up. I also kindly educated the RN on proper usage of Glucose

RR: 12, Resps were fairly normal for her. Pt is usually able to walk with assistance, pt normally Ao3/3 and is usually able to communicate w/o any problems. Pt was on Oxycodone, which the pts PCP just bumped the dose up. No hx of pill hoarding, no recent trips to the hospital or draws done.

No HX of recent illness, but then again, the RN was just back from her 3 days off and did not get a report from the previous RN (whats new about that....seems like they never communicate) Negative on the Foley or bed sores.

You are able to establish an IV line, give an AMP of D50. The pts sugar now reads from "Lo" to 230. Pt now is able to open eyes and is able to look towards you w/eye when verbal stimuli. Pt is still "not back to normal" states RN. You then give .4 Narcan, slowely titrating it up. After a few minutes the pt is able to move spontaneously, turns head towards you when you speak to her, pt is able to speak, but is more of "word salad". Pt is still A&Ox0/3.

On a earlier note i should have mention... This particular SNF, or USNF, is known to have OD pt from time to time...

See now I feel like an *** for semi-disagreeing with n7lxi since she had a positive response from the narcan...

Seems like your leading us towards an accidental opioid OD with the SNF's hx of ODs and the increased dose of Oxycodone along with a hypoglycemic episode. How much of a dose increase was it? are we talking a small change like 5/325s to 7.5/325s or doubling up the narcotic dose to a 10/325?

But with the word salad after treatment I want a full neuro exam. I don't remember if you said it but I'd like a look at her rhythm on a 3/4 lead and possibly a 12-lead if I'm feeling frisky. I'll give the RN the benefit of the doubt with her being gone but if it's possible I'd like a gander at the chart from the past few days as well. After she woke is she complaining of anything? Weakness? Headache? When was this patient last seen normal? How are her pupils now? Hx of HTN and hyperlipidemia + "word salad" after waking makes me think a stroke is possible but I'm like 1 for 4 so far on this scenario so I wouldn't put a whole lot of money on my bet

Sounds like this lady has more than one issue going on. Is she awake enough to give us a reliable Hx? Smoker? Hx of TIAs or CVAs? Has anything like this ever happened to her before? Is she med compliant? Is there a cause of the chronic pain such as surgeries? Is she obese or "nana sized"?

I like what you did with the UNSF statement :rofl:

 

[Handsome Robb]

Makes sense, we use versed/etomidate and succs/vec so it wouldn't be an issue for us, hence it not coming to mind.

Where's the analgesia? I see a sedative(s) and a paralytic but no analgesic. I was under the impression analgesia was a standard of care when it comes to RSI/chemically assisted intubation/post intubation care. Our ground medics can't do RSI but flight here does versed or etomidate + fentanyl + succs or vec.

abckidsmom, someone really did that? I might be young and dumb, but not that dumb! :unsure: Some may disagree with the last statement h34r:

 

[abckidsmom]

abckidsmom, someone really did that? I might be young and dumb, but not that dumb! :unsure: Some may disagree with the last statement h34r:

Not that dumb.

That happen back at the dawn of the new daylight after the dark ages of EMS. It was really funny, in a "boy how stupid can you be" sorta way.

 

[Dwindlin]

Where's the analgesia? I see a sedative(s) and a paralytic but no analgesic. I was under the impression analgesia was a standard of care when it comes to RSI/chemically assisted intubation/post intubation care. Our ground medics can't do RSI but flight here does versed or etomidate + fentanyl + succs or vec.

Not standard of care, but may be in the future as there are some studies showing improved outcomes with analgesia.

 

[truetiger]

Versed/Etomidate works well for us. Used the protocol a few times already and have had no issues.

 

[usalsfyre]

Versed/Etomidate works well for us. Used the protocol a few times already and have had no issues.

Not a good answer. It may appear to work fine but Versed has ZERO analgesic properties meaning your patient is still getting the physiologic affects of pain from your laryngoscopy and having a tube stuck between their cords. Remember that pain affects the hind brain as surely as it affects the more perceptive lobes, causing things like catecholamine dump, ect. They may appear fine, but most sedated and especially paralyzed patients do.

Please don't tell me your routinely using long-term paralysis as well...

 

[usalsfyre]

Not standard of care, but may be in the future as there are some studies showing improved outcomes with analgesia.

It IS the standard of care anywhere outside of ground EMS. You won't find CCT teams, HEMS, EDs, or anesthetist RSI'ing without analgesia on board.

Anyone who doesn't have opiates in their RSI protocol should be using the pain management protocol to treat them as well. And lobbying the hell out of their OMD.

I'll get off my soap box now.

 

[Aidey]

if you give it to some druggy, it can cause them to go in to withdraws and cause sz. Rare, but if it is a long time drug user, and that stuff is in their system, it can cause some serious issues later on. Thats why you normally only give enough just to relieve resp. depression.

Cite your sources on the seizure bit.

 

[usalsfyre]

A well acknowledged side affect of acute withdrawal is seizures, and naloxone has been known to cause acute withdraws.

 

[Handsome Robb]

A well acknowledged side affect of acute withdrawal is seizures, and naloxone has been known to cause acute withdraws.

Seconded. I'll go looking for a reputable source since I know my paramedic text wont suffice here

 

[Aidey]

Without completely diverting the thread my understanding (straight from a doc) is that the risk of seizures in opiate withdrawal decreases with age, assuming no underlying seizure disorder. So babies born addicted have a significant seizure risk, but adults do not. Even when heavy users are thrown into acute withdrawal by narcan.

A search on pubmed for "opiate withdrawal seizures" comes back with 36 results, one of which is about seizures in adults, and the patient was a farking train wreck. A search for "narcan seizures" results in 395 results, and I'm yet to find one that is about narcan causing seizures. A bunch are actually about narcan helping stop seizures in patient's with tramadol induced seizures.

I had a patient appear to develop seizures after narcan. We spoke with an ED doc about it, and he said in 20 years it was the second time he could remember hearing it happen. In the previous case the theory they developed was that the opiates were suppressing the seizure activity caused by severe hypoxia. That was the working theory in our case until we found out that our patient's tox screen came back negative, 4 times. After that it got chalked up to coincidence.

 

[Remeber343]

Cite your sources on the seizure bit.

as I said, it most commonly happens in chronic users/long term users. I remember this tid bit out of our textbook, but here is one site i found within a min or two of searching the web:

http://www.opiates.com/opiate-withdrawal.html

And Rob, I'll get back to you in a bit, I have to run right now and didn't have time to type out the rest of the answers!

 

[Aidey]

Sorry, but a page from a treatment center website is not an academic source.

 

[Remeber343]

I stated i did it very quickly, did i say it was academic? It took me like a minute to even find that, and im sure finding an academic one wont be to terrible hard either, but im short on time right now and thats the best i can do for you at the moment. Its going to have to work until im back at my computer and its easier to research things instead of on the phone.

 

[Dwindlin]

I had the same results essentially as Aidey. I was able to find one case report on PubMed but then in the discussion they remarked the etiology of the seizure was unclear.

After a PubMed fail I checked out Tintinali's and Goldfranks, neither of which mention seizures in adult opioid withdrawal, naturally or narcan induced.

 

[rmabrey]

IF ALL ELSE FAILS PUT SNACK SIZE SNICKERS UP RECTUM TO CORRECT LOW BLOOD SUGAR

Just move the globs or oral glucose to the rectum

Not a good answer. It may appear to work fine but Versed has ZERO analgesic properties meaning your patient is still getting the physiologic affects of pain from your laryngoscopy and having a tube stuck between their cords. Remember that pain affects the hind brain as surely as it affects the more perceptive lobes, causing things like catecholamine dump, ect. They may appear fine, but most sedated and especially paralyzed patients do.

Please don't tell me your routinely using long-term paralysis as well...

Ours is the same as someone else state, versed, Etomidate, and Vec IF absolutely necessary. lack of Analgesia is why I cringe when medics brag about nasally tubing someone with our ET tubes..........yes we have a protocol for that:wacko:

 

[Handsome Robb]

Just move the globs or oral glucose to the rectum


Ours is the same as someone else state, versed, Etomidate, and Vec IF absolutely necessary. lack of Analgesia is why I cringe when medics brag about nasally tubing someone with our ET tubes..........yes we have a protocol for that:wacko:

Our nasal intubation protocol does not include analgesia. However our post intubation sedation/analgesia protocol does include fent and midazolam. Retrograde amnesia is a wonderful thing

 

[rmabrey]

Our nasal intubation protocol does not include analgesia.

DO you use ET tubes though?

 

[jjesusfreak01]

DO you use ET tubes though?

Is there something else you can use? Serious question, enlighten me if there is.

It is interesting to read about the physiological effects of pain. I would have thought Versed and a paralytic would be sufficient for RSI until reading that.