Narcan and hypotension

[vquintessence]

Thank god for our pts that we don't carry flumazenil. Frankly it's because of ignorance that much of EMS has lost it. "Titrate to effect" is too complicated. :glare:

God help us if we lose the security of carrying naloxene. Those stories we hear all too often of pts getting slammed 2 mg IVP... well they get heard out of our realm.

 

[firemedic31075]

If she is gagging on an OPA, she is not completely unresponsive. If she is gagging on an OPA, she doesn't need an OPA. If she doesn't need an OPA, then she darn sure doesn't need an ETT. Not every unconscious person needs an ET tube. An ET tube is not simply a lazy medic's way of getting out of basic airway control. I just don't think you'd find too many medical control physicians who would say this was justified PAI.

I'm sorry but this doesn't make sense to me. You say if she's gagging on an OPA she doesn't need to be intubated via RSI. I though that was the point of RSI, the ability to intubate someone that has a gag reflex. She is unresponsive and had vomited and aspirated a bit before we got there not to mention the slow resp. rate and poor tidal volume. If I walked into the ER with a pt. that has a GCS of 3 and vomit all over their face and didnt have them tubed, I think the first thing they would do is chew me out then tube the pt.

those are my thoughts anyways...Im trying to understand how not intubating this person would be beneficial...

 

[Aliakey]

I'm not trying to start any wars, just kinda confused. With the first post, you indicated that the lungs were clear bilaterally ("LS- clear and Equal bilat."). Your second post states, "After the my partner gave 2mg of narcan IM the pt. began gagging on the OPA and continued to have a gag reflex when we go to the back of the unit so the decision was made to RSI rather than attempt to just tube her and risk vomiting and aspiration". And now I read in your last post, "She is unresponsive and had vomited and aspirated a bit before we got there...". ????? Did she or did she not vomit PTA?

Anyway, for what I've learned and experienced, and of course subject to all sorts of scrutiny :

1. Can the patient protect her own airway?

Gag reflex in itself is not the best indicator of whether a patient can protect her airway or not. A better indicator is a swallow reflex, which is a more complex reflex requiring the patient to sense and initiate an effort to move secretions down the esophagus. Could she swallow? Did anyone take a few seconds to watch? I have seen patients with very low GCS scores still preserve an ability to swallow, particularly those who have overdosed on drugs or alcohol. GCS alone is not a good indicator.

I may have to purchase this paper just because it'll bug me down the road if I don't, but the abstract itself is enlightening: Decreased Glasgow Coma Scale Score Does Not Mandate Endotracheal Intubation in the Emergency Department

Anyway, with the contradicting information presented about this patient so far, this question cannot be answered.


2. Is the patient being oxygenated adequately?

Breathing in itself is not an indication that the airway is protected or that adequate oxygenation is occurring. If the patient has a swallow reflex and can be maintained with her head elevated, can a less invasive means be used instead of an ET tube? How about just long enough to see if a couple of rounds of Narcan might work (seeing that one round apparently improved the patient's responsiveness)?


3. What caused this patient's demise? Personally, I'm on the same boat with the others: Narcan first for the OD scenerio... pharmaceutically-assisted intubation later, if needed. If the patient had already aspirated as suggested in the third post, then then damage has already began. You can tube the patient, deep suction what aspirate you can, push the naloxone, and watch her wake up and fight you to pull the garden hose out of her throat as the Versed quietly wears off when you just turned around "for a second" and not watched her. You'll never get all of the aspirate out with the deep suction anyway, and you risk the tracheal damage from his self-extubation. And on certain patients, they may never be able to breath on their own again once tubed. It's a sad scenerio I've seen happen.

Or, IMHO, better to hope that you can wake the appropriately-positioned patient with the Narcan first and let her cough the crud out of her lungs, on her own. Again though, her ability to swallow is in question, and not something I see being answered in the three contradictory posts.

Just throwing out ideas.

 

[firemedic31075]

sorry for the confusion. When we first got on scene I noticed some vomit on the floor and on her face, when I opened the airway there was still some in there which I suctioned (it looked to me like she may have aspirated a bit). and then put in an OPA (at this time she has no gag reflex) and began ventilation. I listened to lung sounds which were clear and equal. Narcan was given and she began gagging, but no increase in LOC. We decided to intubate but the pt now had a gag reflex so we did not want to risk (vomiting and aspiration) trying to tube her without paralytics.

does that clear things up? or just make it worse? haha

 

[Flight-LP]

That's what I was thinking..our protocol is Etomidate and Succs for RSI (we don't use any opiates in RSI other than a trauma situation) and versed and Vecc for longer duration, which narcan wouldn't affect, so I guess there was no harm in giving it. I myself would not have given it had I been the lead medic. I would have tried other measures to correct the b/p.

No analgesia for RSI?!?!?!?!?!?!?

That's just cruel................

I agree with your last statement, Narcan would have been the last thing on my mind, especially after your pt. bought an ET tube.

 

[boingo]

If she is gagging on an OPA, she is not completely unresponsive. If she is gagging on an OPA, she doesn't need an OPA. If she doesn't need an OPA, then she darn sure doesn't need an ETT. Not every unconscious person needs an ET tube. An ET tube is not simply a lazy medic's way of getting out of basic airway control. I just don't think you'd find too many medical control physicians who would say this was justified PAI.

That is just extremely poor planning and decision making to hit someone with naloxone and then RSI them.

Very well put.

 

[boingo]

I think the problem people are having, at least I'm having is if you find someone that you feel has overdosed on an opiate, and your plan is to correct their respiratory status by reversing it with narcan, fine, but you don't go down that road, and now, as the narcan is doing what it is supposed to (increasing respiratory rate and LOC) and the patients gag reflex returns, the next step should be to remove the OPA causing the pt to gag, not to do a 180 and RSI them. If the game plan is to secure the airway, then reversing the effect of the opiate is a bad idea, whether you include an anelgesic in your PAI/RSI algorithm or not.

 

[smurfe]

I have gave Narcan way more times for hypotention than respiratory depression. These are the two reasons you give narcan (respiratory depression and hypotention) and it shouldn't be given just because a narcotic is on board. Flumazenil could of been given to the patient for the Benzo but i don't like to give it as a few times I have the patient had a seizure when they came around and then I was hosed treating that.