Naloxone routes, which and why?

[COmedic17]

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?

sort of.

IN is a " my patient has no respiratory drive, is a transient outside in the cold, wearing 8 layers of clothing meaning several layers will have to be removed before IM or IV is even a possibility, so IN is the fastest route, and I will establish a more reliable route when I am able able" kind of thing.

It's hard to put a blanket term on the "best route" when it can be situational.

 

[NomadicMedic]

Or, IN works... so let's do the least invasive procedure.

 

[STXmedic]

Or, IN works... so let's do the least invasive procedure.

Except when it doesn't... I've given it more than its fair opportunity to prove me wrong. At my last station, I literally had at least one heroin OD per shift. I lost count of how many times IN did not work. IM breaks the skin, but how honestly concerned are you to cause major problems with an IM injection? Use a little alcohol and you'll be fine. My two year old just got three IM injections in the same doctors visit. I'm not all that concerned.

 

[ThisIsTheLastTime]

Except when it doesn't... I've given it more than its fair opportunity to prove me wrong. At my last station, I literally had at least one heroin OD per shift. I lost count of how many times IN did not work. IM breaks the skin, but how honestly concerned are you to cause major problems with an IM injection? Use a little alcohol and you'll be fine. My two year old just got three IM injections in the same doctors visit. I'm not all that concerned.

wow thats powerful. i was just talking to a medic, and his thoughts are that there are too many variables with IN, like if they have a history of snorting drugs or if theyve had their nose cauterized IN can be pretty ineffective. sounds like this was your experience or something like it? anyone else have thoughts on this?

 

[COmedic17]

wow thats powerful. i was just talking to a medic, and his thoughts are that there are too many variables with IN, like if they have a history of snorting drugs or if theyve had their nose cauterized IN can be pretty ineffective. sounds like this was your experience or something like it? anyone else have thoughts on this?

The biggest problem I see with it is if it runs out of the nostrils..usually if someone is fairly congested.

Even if it doesn't immediately get absorbed from previous nasal trauma or what not, it's going to eventually get absorbed as long as it stays in the body. Maybe not as fast as other routes, but it will still get into the system fairly quickly.

 

[NomadicMedic]

I've never had IN Narcan not work. Anecdotally, of course.

 

[Tigger]

I've never tried nor seen IM used, and now that we have safety needles (seriously....) I'd like to try it.

 

[k9Dog]

IN and IM take 2-5 minutes in my experience. IV is immediate of course. IN is easiest, and doesn't require you sticking a needle in someone who likely has hep c or HIV. They all work, however. If the guy is completely apneic, I would have partner bag him and give it IV. If he's unresponsive but still has some respiratory effort, IN.

 

[Smitty213]

I am a huge fan of IM; a senior Medic I had the fortune to work with taught me the value of it about two years ago. IM metabolizes a little slower for a smoother, easier wake-up, it doesn't seem to "wear out" as fast as IN, and you don't have to worry about getting the line in that junkie with veins that are trashed. While not as immediate as IV, it only takes about a minute or so to start working, which is not that much time to assist ventilations for if you take into account total time to set up the line.

 

[COmedic17]

I am a huge fan of IM; a senior Medic I had the fortune to work with taught me the value of it about two years ago. IM metabolizes a little slower for a smoother, easier wake-up, it doesn't seem to "wear out" as fast as IN, and you don't have to worry about getting the line in that junkie with veins that are trashed. While not as immediate as IV, it only takes about a minute or so to start working, which is not that much time to assist ventilations for if you take into account total time to set up the line.

I have never seen IM anything have a profound effect in a minute or less.

 

[Smitty213]

I have never seen IM anything have a profound effect in a minute or less.

It's not profound, which is what makes it nice. I'd say it takes 5 minutes for full effect, but I usually would estimate seeing some minor changes after the first minute or so.

 

[TattooedNay]

The cops in my area are very well trained first responders. If they haven't given IN prior to our arrival I will usually start out with 0.5 IN. It's case by case... Heroin is HUGE around here and unfortunately it's easy to see when the streets are "being cleaned". If there is a bad batch going around maybe 1mg IN. and secure a line. I really prefer to not be covered in vomit and have an irate pt. in the back with me. Transport times are pretty quick so just enough to keep them breathing works for me.

 

[TXmed]

Chicago FD did a study where they gave narcan via nebulizer. I have done it several times and it works great.

 

[STXmedic]

Years ago it used to be standard practice here to give intralingual Narcan. Apparently it worked fairly well- never saw it myself.

 

[NPO]

Our protocols allow IV/IM/IO/IN with no preference towards a particular route. I've only given it IV, but fully willing to give it IN if I have any inclination to believe the patient will be, or is, agitated. I also generally give small doses, just to keep my patient alive and breathing well on their own. I generally leave them still a little sedated for safety and ease.

For semantics, the FDA recommends the IN route becuase its needle-less.

Our protocols also mention considering an IM dose following IV doses to give a prolonged effect to prevent relapse.

Also, if you're interested in some fun party trivia, look up IV drip Narcan for treatment of sepsis.

 

[STXmedic]

Funny that this thread popped up again today. Our third run of the day was a heroin OD. Basics in fire can give IN (only) Narcan, so my partner let one of the basics give 2mg IN when we got there. Again, IN didn't work after a more than reasonable amount of time. 2mg IM worked as expected. It certainly could've been the patient simply required considerably more than 2mg, but it also follows the trend I (anecdotally) see of IN being unreliable and marginally effective.

 

[JIP00]

I too have never had IN not be effective. What is a reasonable amount of time? If you can ventilate without difficulty and keep your Sp02 up what is the rush to intubate or blast someone with IV Narcan? If it's taking them that long to wake up with IN Narcan it's probably polysubstance.

 

[NPO]

I gave narcan IN to try it. Meh.

 

[ALS AXE]

I find that administering naloxone IN with 1-2 mg split between nares can get things moving while you are establishing a IV. Then I reassess and if I elect to administer more, then I may do so through my IV access. But it all depends on what you try ( with in your protocols ) and what you find works best in your system.