Naloxone routes, which and why?

[ThisIsTheLastTime]

Hey there guys, I was hoping to bounce a question off yall. There is a lot of discussion in various threads about IM vs IN naloxone, but it's mostly brief and mentioned in relation to a more main point. I haven't seen any threads specifically comparing the two, so what is your experience and preference, and why?

 

[NomadicMedic]

Snout. No sharps. Works great.

 

[Tigger]

Usually just IV. If they are really out we probably need a line anyway, might as well do that while they aren't moving around. We finally purchased atomizers so I am curious to try them.

 

[NomadicMedic]

Usually just IV. If they are really out we probably need a line anyway, might as well do that while they aren't moving around. We finally purchased atomizers so I am curious to try them.

Curious, why do they need a line if they're "really out"? They really just need Narcan, and if you can do it without sharps, isn't that a better solution? I haven't given IV Narcan in ages.

 

[Tigger]

Curious, why do they need a line if they're "really out"? They really just need Narcan, and if you can do it without sharps, isn't that a better solution? I haven't given IV Narcan in ages.

The prevailing line of thinking is a need (or potential) for airway management indicates a need for IV access. I am not sure where that came from. Often that is the case, but certainly not always. Also several of my partners believe that opiate overdose = severe hypotension.

Nonetheless, if the patient requires an IV, I'd prefer to do that while the patient is obtunded instead of *potentially* agitated.

 

[NomadicMedic]

Okay, fair enough. I believe in building yourself a safety net, but a simple, obvious prehospital opiate OD, at least for me, is a nose full of Narcan and a ride to the ED.

If, after 2mg of Narcan, the patient remained obtunded and exhibited respiratory depression to the point where I needed to support it, they're going to buy a tube.

 

[phideux]

I've only given Narcan IV. I pretty much start at around 0.5mg, push slow, and titrate to effect, just enough to get that respiratory drive up. Pretty hard to titrate IM or with a nasal atomizer. I don't like waking the sleeping junkies up all the way.

 

[Inspir]

Straight from our protocols

"The efficacy of IM naloxone is such that it is the preferred route of administration"

We can also do IV or IO

 

[ThisIsTheLastTime]

Straight from our protocols

"The efficacy of IM naloxone is such that it is the preferred route of administration"

We can also do IV or IO

interesting stuff. seems like there is a disconnect between protocol and practice

 

[ThisIsTheLastTime]

I've only given Narcan IV. I pretty much start at around 0.5mg, push slow, and titrate to effect, just enough to get that respiratory drive up. Pretty hard to titrate IM or with a nasal atomizer. I don't like waking the sleeping junkies up all the way.

right right. no need for a 0-60 i suppose. you worry at all about increased hypoxia in titrating slowly?

 

[TransportJockey]

IV here, titrated to respiratory effort. If I can get that up, but they stay sleeping, I'm ok with that.

 

[phideux]

right right. no need for a 0-60 i suppose. you worry at all about increased hypoxia in titrating slowly?

No worry, assisted ventilation with a BVM and O2 while getting a line and pushing it.

 

[chaz90]

My preference is 1 mg IN off the bat then begin looking for an IV. Typically by the time I have an IV up and running they have either had some improvement in their respiratory status and we can move on, or they haven't and I can administer an additional 0.5 mg IV. I don't really use IM that often for whatever reason.

 

[STXmedic]

2mg IM, typically chased with another 2mg IM after the refusal. I've had a lot of variable results with IN administration, so I just stick with the slightly slower but more reliable IM route.

 

[COmedic17]

Depends on the situation.

There's a big heroin problem in the city where I work. There has been times people have wrecked their vehicles while driving..one instance, a person had been shooting up, while driving, and the tourniquet was still on their arm, needle by them, etc. At this point, I obtain an IV because it is a trauma as well as a probable OD.

In somebody with borderline vitals, I typically do IM..slower onset, less likely to get punched in the face before my 5 minute transfer to hospital.

If someone is completely unstable, I will give IN first to get it in their system as quickly as possible. If they don't come around relatively quickly, I will follow with IV or IM.

If all vitals are stable and breathing adequately, I just provide supportive care and withhold Narcan and let the ER decide if they want to give it or let the party come around on their own. I typically try to avoid throw downs in the back of the truck.

 

[ThisIsTheLastTime]

Depends on the situation.

There's a big heroin problem in the city where I work. There has been times people have wrecked their vehicles while driving..one instance, a person had been shooting up, while driving, and the tourniquet was still on their arm, needle by them, etc. At this point, I obtain an IV because it is a trauma as well as a probable OD.

In somebody with borderline vitals, I typically do IM..slower onset, less likely to get punched in the face before my 5 minute transfer to hospital.

If someone is completely unstable, I will give IN first to get it in their system as quickly as possible. If they don't come around relatively quickly, I will follow with IV or IM.

If all vitals are stable and breathing adequately, I just provide supportive care and withhold Narcan and let the ER decide if they want to give it or let the party come around on their own. I typically try to avoid throw downs in the back of the truck.

2mg IM, typically chased with another 2mg IM after the refusal. I've had a lot of variable results with IN administration, so I just stick with the slightly slower but more reliable IM route.

so IN mainly for ease of use? have you started using the new single shot narcan or still amp and atomizer? i feel like there is evidence everywhere for IM over IN but people still choose IN regularly. mostly to avoid needle sticks?

 

[STXmedic]

We use the 2mg prefills with luer lock. For the longest time, the prefills came with an affixed needle- we'd have to pop out the plunger and draw it up in another syringe if we wanted to use the MAD.

Yeah, the biggest reason I've heard is the lack of a needle with the MAD. I prefer the consistent and predictable absorption, so I just don't stab myself... The same goes for versed with seizures or ketamine/versed for the combative patients.

 

[COmedic17]

so IN mainly for ease of use? have you started using the new single shot narcan or still amp and atomizer? i feel like there is evidence everywhere for IM over IN but people still choose IN regularly. mostly to avoid needle sticks?

I went through each senario and why I would use each route. IN if they need it ASAP because it's already set up, quicker admin, then follow with IM or IV. Give them something to work with while I prep everything else.

 

[ThisIsTheLastTime]

We use the 2mg prefills with luer lock. For the longest time, the prefills came with an affixed needle- we'd have to pop out the plunger and draw it up in another syringe if we wanted to use the MAD.

Yeah, the biggest reason I've heard is the lack of a needle with the MAD. I prefer the consistent and predictable absorption, so I just don't stab myself... The same goes for versed with seizures or ketamine/versed for the combative patients.

I went through each senario and why I would use each route. IN if they need it ASAP because it's already set up, quicker admin, then follow with IM or IV. Give them something to work with while I prep everything else.

ok cool, so IM is consistent and predictable and reliable, IN is like using mouthwash when you need to get out of the house, brush your teeth later kind of thing. am i starting to get it?

 

[STXmedic]

Not sure I follow your analogy. When the MAD works as advertised, it's fast and effective. In my experience, it often doesn't work as advertised though. Incorrect technique, excessive mucous, and poor mucous membrane circulation can all affect its absorption. Some people still swear by it as their go-to device. I'm just impatient and don't like waiting around to see if it's going to kick in over some unknown amount of time before I re-dose, when I know the IM would've already kicked in. Use it a bit and form your own opinion. I haven't seen any good evidence stating its absolutely better or worse.