Intranasal Narcan for BLS
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downunderwunda
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Firstly if you are 45 minutes from a hospital that's even more reason to be up skilled to provide all you patients with optimal care.
As I have said in other threads, healthcare should not be run on a 'for profit' basis, but as a function of the state. This said, the education of officers should be provided by that organization.
There will always be people we don't personally trust with drugs & IV's etc, however, if they stuff up internal reporting should weed them out.
If people don't have the mental capacity to increase their skills, see ya. Pure & simple. Ems is a profession. We need 2 things for that to be seen. 1 is increased education & skills & 2 is total separation from fire. Only then can we truly be a profession.
zmedic
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That's fine in the abstract. But this is a volunteer fire department, with about 10 EMTs, almost all of whom are doing something else full time. Recruiting and retaining members is a big issue. It's hard enough to get people to go through a 120 hour class, having everyone take the EMT B and a EMT I as well isn't going to happen, and I'm not sure it is worth it for a place where they run 30 calls a year.
As to making everyone an EMT-I, I think there are plenty of people who I don't think should be doing drug calculations and starting IVs but who I would trust to stick tube up someone's nose and give 0.2mg of Narcan when their friend says they did heroin.
Sure it would be great if everyone was an EMT-I, but I don't see it happening in the current funding situation.
Brandon O
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I am appreciative of the view, espoused by Rogue and others, that all the narcotic OD needs is bagging for his respiratory depression. However, realistically, in this world, ventilating with the BVM alone is not always easy, and if it comes down to the choice between sticking to the "principle of least medicine" and letting someone become hypoxic because you can't seem to reliably get the air in, it would be nice to have an effective out.
This would be somewhat similar to the opinion that giving BLS a King or Combitube is useful, not to replace intubation, but to replace unassisted bag-mask ventilation. The world is finally coming around to the facts that 1. One-person BVM is often quite difficult, and 2. We're not going to do mouth-to-mouth or mouth-to-mask so stop mentioning it. The consequences of this are numerous.
This would be somewhat similar to the opinion that giving BLS a King or Combitube is useful, not to replace intubation, but to replace unassisted bag-mask ventilation. The world is finally coming around to the facts that 1. One-person BVM is often quite difficult, and 2. We're not going to do mouth-to-mouth or mouth-to-mask so stop mentioning it. The consequences of this are numerous.
I cannot buy into this argument at all.
Nobody ever died from not having a plastic tube in them. They die from not having a viable airway.
Somehow back in the days of wooden ships and iron men, when our options were manual maneuver, EOA, or intubation, we somehow managed to ventilate all but the most greviously injured trauma patients where the airway and surrounding structures were destroyed or burned.
These devices are not without their problems, and nobody benefits from from trying to make up for poor technique or lack of skill with a gadget.
What???
I have never had a problem and I have been around a while in some very high volume environments.
This I agree with.
The trouble isn't so much giving a small amount of narcan to avoid having to ventilate a clear isolated narcotic OD. It's hard to justify not doing that, but, in my opinion, the goal should be to avoid artificial ventilation, not to wake the patient to sign a cancellation.
It becomes more of an issue when the patient history is less clear / suspcious for coingestion, where narcan use might unmask more dangerous effects of other agents, and complicate the managment of the patient for several hours. Especially in situations where the evidence for narcotic ingestion is weaker.
This often comes down to the volume of pure narcotic OD versus mixed ODs a system sees, which can vary greatly between different areas, and influences how likely any given patient is to be a pure narcotic OD. It also depends on whether the medical community endorses, openly or otherwise, the practice of giving narcan and doing a cancellation (or, in some centers, scaring the patient away).
I would argue, as well, that in the absence of aspiration or significant pre-existing lung disease, that it should be possible to oxygenate these patients adequately with small minute volumes. The bigger danger in longer periods of BVM ventilation without an adunct is probably distending the stomach and risking regurgitation. Ventilation, i.e. removal of CO2, may be more of an issue.
BLS does get stuck in the situation where reversing an agent may not be possible due to scope of practice, but managing the airway may be difficult because (i) there's no option for advanced airway, or (ii) once the patient's CO2 comes down from decent ventilation with an adjunct, now they're no longer as narcotised, and begin gagging.
However, giving BLS narcan also puts them in a situation where (i) they may unwittingly unmask a mixed overdose patient without having the tools to manage them, or (ii) they may precipitate acute withdrawal syndromes, including seizure activity, without the tools to manage it.
The trouble with a lot of the "EMT+" skills, is you exchange one set of problems for another, and it's not normally, in my opinion, done with a strong enough foundation of physiology, pharmacology, pathophysiology, etc. [That's not intended as a slight to BLS, though I realise it may be perceived as such.].
Brandon O
Puzzled by facies
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In general, I agree, systemet. For what it's worth, here are the requirements for use of BLS nasal narcan in our service:
If evidence of opiate use (patient or bystanders state use, visible paraphernalia, track marks, pinpoint pupils, AMS, respiratory depression, etc.)
and older than 14 years
with no recent seizures
and no trauma
and not in cardiac arrest
and no abnormal breath sounds
and no history of tramadol/Ultram use
and no history of therapeutic opiate use
and no nasal trauma, nasal obstruction, or epistaxis
then give 2mg nasal (1mg per nare) and call ALS. No repetition of dosage is allowed even with medical control permission.
The reason for some of these points are a bit of a mystery for me even now, but there you go -- obviously a very conservative protocol.
But I agree with almost everything you mentioned; that's a well-put summary of the different considerations.
If evidence of opiate use (patient or bystanders state use, visible paraphernalia, track marks, pinpoint pupils, AMS, respiratory depression, etc.)
and older than 14 years
with no recent seizures
and no trauma
and not in cardiac arrest
and no abnormal breath sounds
and no history of tramadol/Ultram use
and no history of therapeutic opiate use
and no nasal trauma, nasal obstruction, or epistaxis
then give 2mg nasal (1mg per nare) and call ALS. No repetition of dosage is allowed even with medical control permission.
The reason for some of these points are a bit of a mystery for me even now, but there you go -- obviously a very conservative protocol.
But I agree with almost everything you mentioned; that's a well-put summary of the different considerations.
Brandon O
Puzzled by facies
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The details of pro/con on blind airways is perhaps a topic for another day -- I'm not necessarily advocating their use by BLS, or indeed anybody. My point is rather than I'm more responsive to the argument that they can serve as a "better" or at least augmented BVM, rather than the argument that they can replace endotracheal intubation. In other words, in a way they may serve a larger need for the BLS provider than the ALS provider.
Well, applause. But many of us, from the lowliest EMT up through the boarded intensivist or emergency physician, regularly encounter difficulty with the pure BVM. Remember that it's one thing to be able to use the tool as a bridge to other interventions, such as intubation (or a bolus of narcan) -- but at the BLS level we have no second act. So what we're actually discussing is being able to take 100% of your opiate overdoses and bag them all the way from your arrival on scene until you turn over care at the ED (or possibly to ALS), consistently, reliably, and without adverse effects. That is a tall order. (If we expand the discussion to the BVM in general, it means taking every patient who needs help breathing and using nothing but the bag. The obese, the traumatic, the anatomically bizarre, the confined-space extrication, everyone.)
Truth be told I've begun to wonder if mouth-to-mask might have more value than we tend to grant it. It's just not on our radar normally, and perhaps it should be.
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That's good, but it's not the case for many providers. I assume there is a reason that 2 person BVM use is now being promoted by the AHA, and I have read many times on this site that one needs to spend some serious time getting competent with the so called "anesthetists grip" before one can truly be good with using a BVM this way.
I support Brandon's idea that so called blind airways may be in fact more useful for BLS providers given their lack of airway management options. Even with the greatest technique and an adequate number of hands, maintaining a mask to face seal is not always going to be easy, and we now have the ability to eliminate this weakness in the artificial respiration process.
Bullets
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I dont quite understand to two person BVM, so AHA is saying you would need 3 rescuers for a CPR, minimum. Unreasonable, BVM use is a skill like splinting, and requires practice, but it is not an impossible skill. As a Basic provider, its one of a handful of skills in our bag. I dont think proper BVM use is difficult
As far as IN Narcan, with proper education, pharmacology, i dont see why not, but i also dont see why
As far as IN Narcan, with proper education, pharmacology, i dont see why not, but i also dont see why
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The person doing compressions can squeeze the bag twice and then return to compressions while the other provider concentrates on maintaining a good seal.
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http://www.ncbi.nlm.nih.gov/pubmed/19913979
small study.
My understanding is the CNS depression from opioids is not only limited to the respiratory system.
That's my oversimplified, rudimentary understanding of it at least.
Brandon O
Puzzled by facies
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If you dig my old EMT textbook off the shelf, and flip to the chapter on airway and respiratory management, you'll find something interesting: it clearly states that the order of preference is two-person BVM, mouth-to-mask, and lastly one-person BVM -- explicitly because maintaining a seal with one hand is simply not very effective. This is actually an old concept, but has been widely ignored, presumably because we're grossed out by getting that close to patients.
I find all this interesting.
Bullets
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No, shouldnt interrupt compressions, especially not for ventilation, which we still havent shown has any real benefit
i probably bag a patient once a week or 10 days. Lots of SNFs in my coverage area.
Amberlamps916
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I've had numerous instructors express their frustrations with providers squeezing bags with way too much force....
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It's not interrupting compressions. Compressions aren't being done while breaths are being delivered if an advanced airway is not in place. So long as the bag is angled the proper way while compressions are occurring and the seal is maintained at all times, it will take well less than 5 seconds to deliver the 2 breaths from the BVM following 30 compressions.
These are AHA guidelines.
Brandon O
Puzzled by facies
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Although in most cases I wouldn't say anything to a provider who chose to give continuous compressions rather than stop to ventilate, in the case of the arrest s/p opiate overdose I think it would be a mistake to skimp on the breathing -- since hypoxia likely caused the problem to begin with.
My knowledge on this is quite limited, but I assumed that in the event of an arrest caused by prolonged respiratory depression/hypoxia that it may improve the chances of survival. I dont have the knowledge & training on that drug so please correct me if I am wrong.
Oxygen reverses hypoxia. Not Narcan.
The only situation I can think of naloxone being useful is a pseudo-PEA secondary to opioid induced hypotension (i.e. never).