Intranasal Narcan for BLS

[Carlos Danger]

The Massachusetts Department of Public Health has been giving prefilled IN Naloxone for several years to the family and friends of opiate drug users. It's been very successful.

You mean they aren't dropping dead left and right from opiate withdrawal?

 

[DrParasite]

Colorado even goes one step further. If you are a civilian, you can now obtain prescription narcan after a 1-hour class and administer it in the field. Drug policy here is extremely progressive.

http://www.leg.state.co.us/clics/cl...5A469A6087257AEE00570637?Open&file=014_01.pdf

Intersting.... giving narcan to civilians who recieve a 1 hour class makes drug policy progressive, but if anyone mentions EMTs giving it, then" omg, we can't trust them with this dangerous medication!!!!"

 

[milehimedic]

Intersting.... giving narcan to civilians who recieve a 1 hour class makes drug policy progressive, but if anyone mentions EMTs giving it, then" omg, we can't trust them with this dangerous medication!!!!"

Don't shoot up the messenger :rofl:

It is different when a person is on-duty and acting in an official capacity than when a civilian is medicating a close friend or family member with a known history.

That said, as an online protocol with all necessary contraindications in districts where ALS could be a while arriving on scene, it can make sense. However, how many districts with a heavy opiate abuse population don't have ALS less than 10 minutes out?

 

[Jon]

Don't shoot up the messenger :rofl:

It is different when a person is on-duty and acting in an official capacity than when a civilian is medicating a close friend or family member with a known history...

Not really. But bigger thing... Is narcan the only solution to the hypoventilation problem? Or can a BLS provider fix the problem for as long as needed with an airway and a BVM?

 

[Carlos Danger]

Not really. But bigger thing... Is narcan the only solution to the hypoventilation problem? Or can a BLS provider fix the problem for as long as needed with an airway and a BVM?

Not most EMT's I've known.

 

[NomadicMedic]

Not most EMT's I've known.

Agreed. Most EMTs with a BVM resemble a monkey with a football.

Not really their fault, but poor education and lack of any opportunity to practice on real people

 

[Carlos Danger]

Agreed. Most EMTs with a BVM resemble a monkey with a football.

Not really their fault, but poor education and lack of any opportunity to practice on real people

:rofl: It's funny cuz it's true.

And most paramedics I've seen were no more proficient at it than their BLS partners. I'll freely admit that I wasn't as good at it as I should have been, even as (especially as) someone who did a lot of RSI's.

It isn't easy to properly ventilate a patient who isn't breathing adequately, but also probably isn't completely relaxed. Some patients (thick beards, stiff necks or jaws, large tongue, sleep apnea, etc) are nearly impossible to effectively BVM even in good circumstances, then add in moving and transferring. Not to mention the fact that these patients aren't NPO, and likely aren't protecting their airway properly.

Small doses of IM or IN narcan is the way to go if a patient isn't breathing and protecting their airway, IMO.

 

[NomadicMedic]

I agree, many medics suck at the BVM, simply from lack of practice. I'm not great, but better than most, just because I've done it a bunch. And I'm not afraid to enlist help to get a good seal and have someone else squeeze the bag for me.

Squeezing 10 breaths into a plastic head in the intubation check if action does not make you skilled at bagging.

In my paramedic program, we did an exercise called "bag a buddy" where you had to ventilate a partner with a BVM for an extended period of time. Uncomfortable and difficult, to say the least. Although after a few sessions, I could get pretty comfortable. It's one of those skills that takes some real practice.

 

[Craig Alan Evans]

It could work well, but like NY pointed out it could turn bad as well. BVM + OPA or NPA works just fine...I could see standing orders for an arrest with opiod OD suspected but then you get into the argument of allowing basics to gain IV access because IM isn't going to cut it in that situation, not sure about IN but I don't see it working too well.

It is much safer to train BLS providers to give Narcan than it is to have them pump the patients stomach up with air, cause them to vomit, and aspirate. I believe IN Narcan is light years above of BVM+OPA for BLS providers.

 

[NomadicMedic]

Just had a respiratory arrest that fully illustrated the lack of EMT skill in bagging. It became a teaching experience while I was getting ready to RSI the patient. Having ETCO2 as a visual guide was a help.

Also, narcan would have done nothing in this case, except needlessly delay BVM use.

 

[Milla3P]

I'm not going to lie; I haven't read all 90 posts in this thread so I don't know if this has come up. BUT:

My state has had nasal narcan for BLS for a couple of years. The same amount of time ALS has had both IN narcan and Versed.

I've done both IN and IM with both narcan and versed and feel that IM is superior in all aspects.

IM is a relatively rapid and predictable administration route.

I feel that IN is not. There is patience required. Most inexperienced BLS providers get a little too amped up when somebody isn't breathing. Add on top of that that they get to give *GASP* a drug (zomg!!!!!) and the Provider usually presses a hair on the fast side and doesn't properly atomize the drug. The drug doesn't properly stick to the mucosa and starts dripping down the airway and is counter productive.

Like I've said I've given narcan both of the possible BLS routes and prefer IM. Hell I think IM is better than IV when I think that 0.4 will make them come to completely. I hate waking opioid addicts.

 

[Tigger]

For what it's worth the majority of the issues associate with EMTs giving IN Naloxone can be attribute to training issues. If they're giving it to fast or when it's not indicated, that's not a medication safety issue. If you're people can't be trusted to give it properly, then don't allow them to. But that doesn't mean that there aren't many out there working for services that do have the proper programs in place to ensure successful use of the medication.

 

[the_negro_puppy]

I'm not going to lie; I haven't read all 90 posts in this thread so I don't know if this has come up. BUT:

My state has had nasal narcan for BLS for a couple of years. The same amount of time ALS has had both IN narcan and Versed.

I've done both IN and IM with both narcan and versed and feel that IM is superior in all aspects.

IM is a relatively rapid and predictable administration route.

I feel that IN is not. There is patience required. Most inexperienced BLS providers get a little too amped up when somebody isn't breathing. Add on top of that that they get to give *GASP* a drug (zomg!!!!!) and the Provider usually presses a hair on the fast side and doesn't properly atomize the drug. The drug doesn't properly stick to the mucosa and starts dripping down the airway and is counter productive.

Like I've said I've given narcan both of the possible BLS routes and prefer IM. Hell I think IM is better than IV when I think that 0.4 will make them come to completely. I hate waking opioid addicts.

Our protocols are 1.6mg IM only. (Intensive Care can give iv) :huh:

 

[Trashtruck]

Hell I think IM is better than IV when I think that 0.4 will make them come to completely. I hate waking opioid addicts.

Ummm...0.4mg IM???

If we're giving Narcan IM or IN, it's 2mg right off the bat.

 

[rwik123]

Ummm...0.4mg IM???

If we're giving Narcan IM or IN, it's 2mg right off the bat.

umm no it's not. Have fun slamming 2mg's of narcan. My protocols call for titrating to effect in 0.4 increments.

 

[Trashtruck]

I can assure you, rwik123, it is.

If you reread my post, you'll notice the administration route is IM and IN, which we do not titrate in 0.4mg increments. It starts at 2mg.

If I were giving Narcan, IV, it would be given in 0.4mg increments.

I see that you're an EMT-B. Do you give IM/IN Narcan in 0.4mg increments?

 

[TransportJockey]

I can assure you, rwik123, it is.

If you reread my post, you'll notice the administration route is IM and IN, which we do not titrate in 0.4mg increments. It starts at 2mg.

If I were giving Narcan, IV, it would be given in 0.4mg increments.

I see that you're an EMT-B. Do you give IM/IN Narcan in 0.4mg increments?

Our basics give it 0.4 starting for IM and 2mg for IN. But most services don't do IN anymore since their basics can just do IM. Besides if I don't have to wake a junkie up then I'm happy.

 

[rwik123]

I can assure you, rwik123, it is.

If you reread my post, you'll notice the administration route is IM and IN, which we do not titrate in 0.4mg increments. It starts at 2mg.

If I were giving Narcan, IV, it would be given in 0.4mg increments.

I see that you're an EMT-B. Do you give IM/IN Narcan in 0.4mg increments?

Well you may not, but we do. EMT-I. Haven't updated my profile in a while.

 

[Milla3P]

I can assure you, rwik123, it is.

If you reread my post, you'll notice the administration route is IM and IN, which we do not titrate in 0.4mg increments. It starts at 2mg.

Nightmare. The last thing I want to do is wake these jamokes up. I just want them to breathe independently (professionally, not personally).

So yes. 0.4 IM. If I'm REALLY concerned and they're small they get 0.2 IV. Narcan is for respiratory issues related to opioid overdose. Not "fixing" them.

 

[Bullets]

So the county immediately south of us has approved IN Narcan for all police officers....

This is due to a more than doubling of fatal heroin overdoses in from 2012 to 2013 to a whopping 112. But heres the even better part, if a police officer is also an EMT, they can not carry or administer because DOH doesnt allow it.

I still think this is a bad idea, mostly because i find giving cops a 1 hour class and then carrying a temperature sensitive drug in the trunk of their car for .01% of the population absolutely ridiculous. I know our cops trash their medical bags and AEDs and leave them in the cars overnight even when its below freezing so i can see this ending poorly when its been below zero for days and they try to administer this