Naloxone Admin By EMT's

@chaz90: not PPV ventilation, just a standard mask (versus the T-pce style neb) and a neb, just like albutarol. Mind you, in respiratory circles they commonly use vents to administer aerosolized medications. Its called IPPB. No one really uses it in Canada but its big in the US.
 
ThadeusJ said:
@chaz90: not PPV ventilation, just a standard mask (versus the T-pce style neb) and a neb, just like albutarol. Mind you, in respiratory circles they commonly use vents to administer aerosolized medications. Its called IPPB. No one really uses it in Canada but its big in the US.
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Right, but how does that work if the patient is apneic if you're not actually ventilating? I feel like I'm missing something here, so perhaps my tired brain just isn't operating properly.
 
If apnea is involved it won't work and the situation is more serious. In that situation it would be very hard to titrate and the IV route or nasal aerosol would be the only options. I suppose you could intubate and use a neb hooked into the vent circuit until spontaneous resps and other vitals come back but thats getting tricky perhaps straying a bit too far from conventional treatment. And that's only to prevent the patient from waking up too fast and leaving before the performance is over.
 
Bullets said:
2mg flat dose is not appropriate. We should be allowed to tiitrate the dose for effect, instead of giving everyone a dose they may not need


Dead serious, i dont like narcan and i have issues with the way it came about and how its used.


If ventilation is sufficient to revive these patients, why give drugs front line? Dont we use vagal maneuvers before we go to meds? Meds before electricity? Just levels of treatment

Im not saying 4 hours is all it takes, currently the class the state has rolled out to LEO/EMS agencies who are looking to carry Narcan is 4 hours. I feel if you are going to only give 4 hours to treating this, the focus should be on proper ventilation and BVM use.
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I think you totally miss the point of having IN narcan in the hands of basic EMT's or cops. There are NUMEROUS reports of saves by LE who are first on the scene with an OD. They aren't going to have good (if any) airway skills. For that matter, most non-anesthesia folks have horrible BVM skills, and you certainly won't learn that in a four hour class. However, a good four hour class for using IN narcan is going to be a cheap way to save some lives - it already has. They're on the news when their department gets it and on the news when they have a save.

Ventilation in a narcotic OD does NOT revive apneic or near-apneic patients. They are not going to wake up just because you're ventilating them. You need to think about that statement again. If they do, then narcotic OD wasn't their problem to begin with.

Do we use "meds before electricity"? Hmmmmm. Think about that statement again as well and perhaps go back and review your ACLS.

Not sure how long you've been doing this, but I suspect narcan has been around a lot longer than you, so I'm not sure how you can have a problem with the way it came about, and considering it's success, I'm not sure how you can have a problem with how it's used - except that you're getting beat to the punch on a save by a cop with a four hour narcan course. IMHO
 
jwk said:
I think you totally miss the point of having IN narcan in the hands of basic EMT's or cops. There are NUMEROUS reports of saves by LE who are first on the scene with an OD. They aren't going to have good (if any) airway skills. For that matter, most non-anesthesia folks have horrible BVM skills, and you certainly won't learn that in a four hour class. However, a good four hour class for using IN narcan is going to be a cheap way to save some lives - it already has. They're on the news when their department gets it and on the news when they have a save.

Ventilation in a narcotic OD does NOT revive apneic or near-apneic patients. They are not going to wake up just because you're ventilating them. You need to think about that statement again. If they do, then narcotic OD wasn't their problem to begin with.

Do we use "meds before electricity"? Hmmmmm. Think about that statement again as well and perhaps go back and review your ACLS.

Not sure how long you've been doing this, but I suspect narcan has been around a lot longer than you, so I'm not sure how you can have a problem with the way it came about, and considering it's success, I'm not sure how you can have a problem with how it's used - except that you're getting beat to the punch on a save by a cop with a four hour narcan course. IMHO
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NJ, so weve had Narcan for about a year now in hands that are not ALS providers. My issue i with this is that this was slammed through by the police departments, which forced DOH to catch up. So now we could carry narcan but still cant use a glucometer.

There are numerous reports of saves because its in the interest of the police departments to make it public that this massive taxpayer funded program is "doing something" so they call the papers and get the dogs and ponys out for one save a town might do a year. Weve been told in NJ that we are locked in a life and death struggle with this heroin epidemic yet the busiest towns in this county have done single digit opiod overdoses last year and this. Obviously i can only speak to the specific situation in my area of NJ, but the numbers arent supporting the success
 
double post
 
Bullets said:
NJ, so weve had Narcan for about a year now in hands that are not ALS providers. My issue i with this is that this was slammed through by the police departments, which forced DOH to catch up. So now we could carry narcan but still cant use a glucometer.

There are numerous reports of saves because its in the interest of the police departments to make it public that this massive taxpayer funded program is "doing something" so they call the papers and get the dogs and ponys out for one save a town might do a year. Weve been told in NJ that we are locked in a life and death struggle with this heroin epidemic yet the busiest towns in this county have done single digit opiod overdoses last year and this. Obviously i can only speak to the specific situation in my area of NJ, but the numbers arent supporting the success
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Then we should also stop doing CPR, because more often then not the outcome is grim? They should make it public. It is in the interest of everyone, why not have a good story on the news, ESPECIALLY with all the crap PDs are putting up with now-a-days?

It sounds like you are a little mad that PDs have the same scope of practice as you in a backward state for EMS. All on the same team, who cares who gets the "save".
 
Bullets said:
NJ, so weve had Narcan for about a year now in hands that are not ALS providers. My issue i with this is that this was slammed through by the police departments, which forced DOH to catch up. So now we could carry narcan but still cant use a glucometer.
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"Slammed through"? So what? It's easy. Person not breathing = suspect opioid involvment = give nalaxone. It's not rocket science.

I agree that being able to use nalaxone but not a glucometer is dumb. So get things changed to allow use of a glucometer.

Bullets said:
There are numerous reports of saves because its in the interest of the police departments to make it public that this massive taxpayer funded program is "doing something" so they call the papers and get the dogs and ponys out for one save a town might do a year. Weve been told in NJ that we are locked in a life and death struggle with this heroin epidemic yet the busiest towns in this county have done single digit opiod overdoses last year and this. Obviously i can only speak to the specific situation in my area of NJ, but the numbers arent supporting the success
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Yes, this is what public safety agencies do.....they toot their own horn as loudly as possible at any opportunity for publicity. I find it rather off-putting as well.

But that has absolutely nothing to do with the clinical question of whether cops should be using naloxone. A save is a save. If cops are getting these people breathing again before EMS arrives......how do you possibly justify being against that?
 
Just a thought... if we can't trust these cops and EMTs to provide rescue breaths or BVM, then they shouldn't have those skills or should be further trained.

IF you cannot trust their airway skills for short duration assisted ventilation, how can you expect them to deal with other airway issues like a common side effect of giving 2mg of naloxone: emesis. (which is why titration is desirable)

I bet they call it a save even if the patient ends up dying of ARDS in the ICU s/p aspiration pneumonia. I don't have data on the prevalence of these complications for lay and BLS administered naxolone but it would be an interesting study.
 
Isn't a solution that actually solves the problem of why that particular patient isn't breathing and gets the patient breathing again better than one that doesn't?

After all, you're not gonna argue that cops and BLS should only manually pump the heart instead of using a proven intervention to restart it (AED) are you?
 
Summit said:
Just a thought... if we can't trust these cops and EMTs to provide rescue breaths or BVM, then they shouldn't have those skills or should be further trained.

IF you cannot trust their airway skills for short duration assisted ventilation, how can you expect them to deal with other airway issues like a common side effect of giving 2mg of naloxone: emesis. (which is why titration is desirable)

I bet they call it a save even if the patient ends up dying of ARDS in the ICU s/p aspiration pneumonia. I don't have data on the prevalence of these complications for lay and BLS administered naxolone but it would be an interesting study.
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Isn't the possibility of aspiration preferable to the larger risk of death if LE comes across an apneic and severely hypoxic opioid OD and EMS is still some distance away? Teaching LEO/medical laypeople to administer 2 mg IN Naloxone then roll the patient to their side sounds to me to be an appropriate treatment with a high reward and relatively low risk. Aspiration pneumonia is also of course a possibility after poor or prolonged attempts at utilizing a BVM with poor techniques and hyperventilation. More training and emphasis on proper use of the BVM for the entire EMS community is a worthy goal, but perhaps not the same issue as increased access to Naloxone.

In most areas I imagine that some variety of first response or transport capable EMS (at least at the BLS level) should be pretty close behind LE entering these scenes. With that in mind, I could certainly get behind the argument that simply equipping first response or BLS units with Narcan could be a positive first step. Even if their ability to utilize a BVM may not be 100% perfect (or let's be real, possibly completely inadequate), they do at least have some understanding of basic airway management and suction devices available. I can't say I see too many people begin profusely vomiting after IN Narcan either, and they certainly do a better job oxygenating themselves with return of spontaneous resps than I usually see with the initial attempts at using a BVM.

I think this has the potential to save lives. We talk about the importance of bystander CPR and public access AEDs, which I completely support of course, but I see way more potentially viable opioid ODs than I do witnessed cardiac arrests.
 
Summit said:
Just a thought... if we can't trust these cops and EMTs to provide rescue breaths or BVM, then they shouldn't have those skills or should be further trained.

IF you cannot trust their airway skills for short duration assisted ventilation, how can you expect them to deal with other airway issues like a common side effect of giving 2mg of naloxone: emesis. (which is why titration is desirable)

I bet they call it a save even if the patient ends up dying of ARDS in the ICU s/p aspiration pneumonia. I don't have data on the prevalence of these complications for lay and BLS administered naxolone but it would be an interesting study.
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So what are the options here?

1. Cop gives narcan, takes a chance that it causes emesis or another bad side effect.

2. Cop does lousy airway management with a BVM, ventilates the lungs poorly, insuflates the gut, takes a chance that it causes emesis or another bad side effect.

3. Cop does nothing but stand by and call on the radio asking EMS to "expedite".

Number 3 is the status quo, and number 2 is what is most likely to happen if you try to train these guys to use a BVM - even a modicum of proficiency with airway management is never going to happen.


Nalaxone administration does include risks, especially at higher doses. Hypertension, tachycardia, and nausea, among others. However.......I don't think any of those are as hazardous to one's health as apnea.
 
I am in favor of BLS and even lay rescuers having naloxone.

Rereading my post, I didn't communicate clearly.

What I have a problem with is the writing off of airway management for anyone below Paramedic! The lack of focus on this critical skill is atrocious.
 
Summit said:
I am in favor of BLS and even lay rescuers having naloxone.

Rereading my post, I didn't communicate clearly.

What I have a problem with is the writing off of airway management for anyone below Paramedic! The lack of focus on this critical skill is atrocious.
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I definitely agree.....but the reality is that it takes more practice to master BVM ventilation than most EMS programs and agencies (and certainly police departments) are going to invest in.

My opinion is drifting towards more liberal use of SGA's by BLS in lieu of BVM management.
 
Remi said:
I definitely agree.....but the reality is that it takes more practice to master BVM ventilation than most EMS programs and agencies (and certainly police departments) are going to invest in.

My opinion is drifting towards more liberal use of SGA's by BLS in lieu of BVM management.
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Could you expand on the latter point? Why would more liberal use of SGAs be in lieu of BVMs?
 
EpiEMS said:
Could you expand on the latter point? Why would more liberal use of SGAs be in lieu of BVMs?
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I just mean I we clearly need an alternative to BVM ventilation for BLS providers.
 
I just read the last few posts only. I think Remi is saying that people are usually poor at getting a good seal with a bag valve mask so he thinks it might be better to consider using a supraglottic airway more frequently so you don't have to worry about getting a good seal. When he says using a BVM, he means bag-mask ventilation. You are still going to use a bag valve mask to ventilate via the supraglottic airway rather than the mask being applied to the face.
 
EpiEMS said:
Could you expand on the latter point? Why would more liberal use of SGAs be in lieu of BVMs?
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Much easier to learn how to pop in a SGA than to teach someone to create a good seal with a BVM. Even after 40 hours in the OR I'm still trash with the BVM, but putting in LMA's is no problem after doing it a couple times.
 
^^truth. An SGA should be the airway of choice for an arrest, both BLS and ALS.
 
Makes sense to me, just wanted to clarify. Thanks!
 
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