Narcan or not

[rmabrey]

The other night my partner and I get called to an unconscious 20 y/o male, bystanders cant tell if hes breathing or not. We get on scene and the Volly FD for the area has every truck they run on scene.

Walk in, Pt is unconscious, on a backboard w/ OP airway and FD is bagging. Bystanders have been on scene approx 15 minutes and only came to check on the PT., no idea how long he has been down. GCS 3, cyanotic, has a pulse, pupils constricted and non reactive. Bystanders st Pt. has overdosed on klonopin and seroquel before and has talked about doing it again, those are the only meds we find in the apartment.

Partner establishes an IV, 250 NS, and gives Versed, attempt 1 size 7.0 ET unsuccessful attempt 2 size 6.0 unsuccessful. I get a combitube, Etomidate given en route. As we are loading the patient up his brother shows up and tells us he probably took Opana.

Without going into all the boring details of what the Doctor, Pts mother (also a doctor) and Fireman who is a medic student said to us and the lab results, given the information presented would you have given narcan?

 

[fast65]

Yup, I would have.


Sent from my iPhone using Tapatalk

 

[exodus]

Sure. Almost All indications there, no contra's. I wouldn't have tubed him either.

 

[ArcticKat]

Yup, I would have given it as soon as I had a line started. I tried giving it intranasally once but it didn't seem to work as well. As soon as we started a line and gave her Narcan IV she woke right up.

 

[rmabrey]

Ill go ahead and add the rest before I go to work.

Pts mom, and medic student said we should have given Narcan. ER Doc asked why it wasnt given and my partner told him.

No opiates were found in his system and he went to ICU within 30 minutes. The hospital never gave Narcan.


So my next question is, why constricted pupils? Dont Benzos dilate the pupils?

 

[Aidey]

Yup, I would have tried narcan. Our medical director gets a little irritated when we RSI people without giving narcan and checking their blood sugar first. Something about doing a highly invasive procedure without attempting to fix the underlying problem first.

Also, what makes you think this was from the klonopin? Read up on the side effects of a seroquel OD.

 

[Smash]

I don't see any indications to give naloxone. Sure, he has miosis and respiratory depression, but there are more things than just opioids that will cause this. I realise that the brother turned up after you managed his airway, but that is just bad luck, you can only act on the information that you find at the time, and you found nothing to make you suspect opioids were part of the problem.

Also not knowing how long he has been down, you are taking a big gamble that he has not had a prolonged hypoxia and a blue brain as a result. There's nothing worse than bringing a patient up to a GCS of 8, having them combative and difficult to manage, and also doing their ICP no favours. I've seen it happen a few times, it's not pretty (I may even have been responsible for it a couple of times...)

I would elect in this patient to ventilate, and depending on how well that was working and how far it was to hospital, RSI and intubate. I think versed only and then forcing a tube is a very bad idea.

I think giving narcan before RSI is a bit silly, as it has then eliminated one of your induction agents (if you choose to use an opioid: I do) and definitely one of the maintenance agents, making the job more difficult and the patient more unhappy with having a tube down his throat. Blood sugar check though, absolutely.

 

[ArcticKat]

I can see where you're coming from Smash but I respectfully disagree for the following reasons:

1. Narcan can work on more than just opoids, including benzos. Just not as effectively.
http://het.sagepub.com/content/early/2010/06/22/0960327110374972

2. He's already overdosed on a benzo, why give him more for an RSI?

3. His GCS was 3, was an RSI even required? Did he have a gag reflex?
(I don't know this, it's not in the OP)

4. If the Narcan is ineffective, then he will still have a GCS of 3, intubate then. In this particular case, intubation didn't work anyways.

I feel it would be appropriate to be using a BVM to support resps while giving Narcan, it will provide sufficient oxygenation until such time as the Narcan is determined ineffective. About 1 minute. It would take that long just to set up the intubation anyways.

 

[exodus]

Also, who's to say he didn't go to the corner, buy 20 vicodin's, down them in the car, and walked inside to die in his home. He wouldn't of wanted the evidence there, that would make it easier for people to save him. He wanted an out and may have thought it through.

(Not speaking on this specific case, but in general about OD's)

He presented with an opiod OD, Imminent resp arrest, pinpoint pupils, aloc. Only thing missing was the actual fact he took opiods.

 

[Handsome Robb]

3. His GCS was 3, was an RSI even required? Did he have a gag reflex?
(I don't know this, it's not in the OP)

This was my first thought.

I'd give the narcan, personally.

If he truly had a GCS of 3 RSI shouldn't be required so I'm not super worried about antagonizing narcs that I would give for induction/maintenance.

There is no direct evidence of opiate OD but the pt has a hx of attempted OD and threatened to repeat the attempt (per friends on scene) + pinpoint pupils + respiratory depression/imminent respiratory arrest + ALOC. I say give it. Risk vs. Benefits.

 

[EMT11KDL]

From the information provided, Yes I would have given Narcan also. You had indications for it.

In the field, we never get the compete history or story of what happened. We make split second decisions on the signs and symptoms that are present at the time. he met the qualifications for narcan.

 

[Fish]

Narcan before even thinking of a tube for sure, and even if that didn't work you didn't need to give Versed to this guy before intubating. He already had a GCS of 3. Narcan is sooooooo harmless, don't be sceeeeerd.

 

[Fish]

This was my first thought.

I'd give the narcan, personally.

If he truly had a GCS of 3 RSI shouldn't be required so I'm not super worried about antagonizing narcs that I would give for induction/maintenance.

There is no direct evidence of opiate OD but the pt has a hx of attempted OD and threatened to repeat the attempt (per friends on scene) + pinpoint pupils + respiratory depression/imminent respiratory arrest + ALOC. I say give it. Risk vs. Benefits.

I'd still give succs or Roc, but no need for the Versed of Etomidate.

This Pt. should of Never been tube in the first place.


But I am curious, what DID the Fire Medic say on scene?

 

[DrParasite]

I'm curious.... what is the downside to administering Narcan in this patient? Other than the cost of the medication, if you give it and it doesn't work, what have you lost? what are the negative side effects? are there any?

 

[Smash]

I can see where you're coming from Smash but I respectfully disagree for the following reasons:

1. Narcan can work on more than just opoids, including benzos. Just not as effectively.
http://het.sagepub.com/content/early/2010/06/22/0960327110374972

2. He's already overdosed on a benzo, why give him more for an RSI?

3. His GCS was 3, was an RSI even required? Did he have a gag reflex?
(I don't know this, it's not in the OP)

4. If the Narcan is ineffective, then he will still have a GCS of 3, intubate then. In this particular case, intubation didn't work anyways.

1. Notwithstanding a small study from Tehran, I doubt that you (or anyone) would consider narcan to be a standard of care in the treatment of benzodiazepine overdose, never mind the seroquel.

2. Whether you elect to give more benzo should you choose to RSI this patient is not the point. The point is whether you give narcan or intubate. Even if you elect to intubate this patient without RSI, opioids are still required for maintenance of the tube once it is placed.

3. As I'm sure you are aware, a GCS of 3 does not mean no gag reflex. I'm not too keen to find out by causing an eruption of Volcano Budpizzarus when I whack a cold blade down there.

4. Indeed this is true. If it were reasonable to expect that he would respond to narcan, and ended up not responding, then fair enough, we play the hand we are dealt. However I have no reasonable expectation that a person who appears to have overdosed on benzodiazepines and atypical antipsychotics will respond to narcan. This then creates a problem when or if we elect to intubate.

I would like to think that anyone who is intubating anything other than corpses is doing it with a decent RSI protocol. This includes an opioid at some stage, usually a short acting one like fentanyl, remifentanyl or sufentanyl during induction and something like fentanyl or morphine for ongoing analgesia. I realise that the evidence for opioids having an effect on mortality when used in RSI is non-existent, however I still consider them to be important. Intubation is a painful procedure, so whether or not the elimination of sympathetic tone to mitigate ICP spikes is effective or not, it seems more than reasonable to include an opioid during induction for humane reasons if nothing else.
Opioids are also vital for ongoing analgesia post intubation. In fact analgesia is the most important part of the post intubation package, with sedation being the added bonus for the patient.
So if we go giving narcan to a patient we have no reason to expect a response to, we are setting ourselves up to provide sub-standard care subsequently.

Also, who's to say he didn't go to the corner, buy 20 vicodin's, down them in the car, and walked inside to die in his home. He wouldn't of wanted the evidence there, that would make it easier for people to save him. He wanted an out and may have thought it through.

(Not speaking on this specific case, but in general about OD's)

He presented with an opiod OD, Imminent resp arrest, pinpoint pupils, aloc. Only thing missing was the actual fact he took opiods.

No, he didn't present with an opioid overdose, he presented with CNS depression in the setting of a presumed overdose on benzodiazepines and atypical antispychotics.

Who can say he didn't take vicodins? No-one. Who can say he hasn't had a brainstem infarct? Who can say he hasn't been hit on the head with a small meteorite and his hair is hiding the wound? Speculation is fun, but the facts of the matter as stated by the OP is that there is no evidence of opioid overdose.

 

[Fish]

I still say Pin point pupils is reason enough to push Narcan before you are going to intubate someone, period. I don't need a needle hanging out of someones arm, or an empty bottle of morphine to convince me that maybe i should try Narcan before intubating someone, seeing as if the Narcan works well hey I no need to intubate, if it doesn't, well then that rules that out and now we are dealing with something else.

 

[firecoins]

Walk in, Pt is unconscious, on a backboard w/ OP airway and FD is bagging.

I am confused. The patient was given an oral airway prior to arrival. So the patient didn't have a gag reflex. Pt could be tubed without the need for more benzos. If more benzos are needed to maintain, they should be given enroute to the hospital.

 

[ArcticKat]

I am confused. The patient was given an oral airway prior to arrival. So the patient didn't have a gag reflex.

Whoa, nice catch, I shoulda caught that.

 

[rmabrey]

Im tired and in the middle of 5 straight 12's so when I get a break I will answer what questions I can. As for tubing the patient and versed all I can say is the dreaded word PROTOCOL.

Whether or not my partner should have given Narcan ( i would have with my limited knowledge) I wont fault him cause he is much smarter than I and he followed protocol........He either got lucky or knew what he was doing.


Found out today he also took a chemotherapy drug of some sorts. He was transferred to a psychiatric facility today.

 

[McGoo]

I am confused. The patient was given an oral airway prior to arrival. So the patient didn't have a gag reflex. Pt could be tubed without the need for more benzos. If more benzos are needed to maintain, they should be given enroute to the hospital.

Not necessarily. I have had a pt with GCS 3, took an OPA with no complaints, but gagged when the tube hit his cords.