Narcan or not

[medicsb]

I guess I can claim Team Narcan on this one.

I still think that a known overdose of one drug suggests a possible overdose of another. It isn't a stretch for someone to also OD on an opiate, but the pontine hemorrhage or a small meteor is a little more remote. Narcan in the appropriate doses is likely to be harmless, and if it works, then even better - you've avoided a tube (at least temporarily).

Anyhow, the problem with naloxone be can overcome with a larger dose of an opiate as naloxone is a competitive antagonist. Considering the massive doses of fentanyl that can be given, I don't think a dose 2-3 times higher than usual will cause many problems in the intubated, non-trauma patient.

 

[McGoo]

If the patient is being ventilated adequately with an OpA and a BVM, I don't see an immediate need for narcan, but I would probably still give it. I would most likely give 1mg IM, see what happens, give more if it has an effect. But I wouldn't give enough to wake him up, only enough to maintain a patent airway.

 

[Sodapop]

Assuming the Airway and BVM was getting good ventilation I would have tried the Narcan as soon as I had the IV. If the Narcan did not work then I would have intubated the patient.

Since he had an airway in place upon arrival at the ER I would have to think that would impact whether they try Narcan or not.

I could be wrong here but as I understand it Narcan will block the effects the drug is having on the respiratory system and return the patients respiration to more normal level. It does not remove the effecting drug so that is still in the system and as the Narcan wears off the respiration's will decrease again and an additional dose of Narcan will be required to sustain proper respiration's. In the given situation the patient was delivered to the hospital with a controlled airway so the use of Narcan is not necessary and if it was a drug OD causing the resp. depression the drug can run it's course, leave the system and the resp. would return and the airway could be removed.

So I would have tried it but I also see where not using it could be deemed appropriate as well assuming the airway can be controlled.

 

[Fish]

Assuming the Airway and BVM was getting good ventilation I would have tried the Narcan as soon as I had the IV. If the Narcan did not work then I would have intubated the patient.

Since he had an airway in place upon arrival at the ER I would have to think that would impact whether they try Narcan or not.

I could be wrong here but as I understand it Narcan will block the effects the drug is having on the respiratory system and return the patients respiration to more normal level. It does not remove the effecting drug so that is still in the system and as the Narcan wears off the respiration's will decrease again and an additional dose of Narcan will be required to sustain proper respiration's. In the given situation the patient was delivered to the hospital with a controlled airway so the use of Narcan is not necessary and if it was a drug OD causing the resp. depression the drug can run it's course, leave the system and the resp. would return and the airway could be removed.

So I would have tried it but I also see where not using it could be deemed appropriate as well assuming the airway can be controlled.

Right and wrong, the more people you can prevent from being intubated and kept off of a ventilator, the better. Narcan should ahve been used, a call review at our system would have been generated for something like this if Narcan was not given since it is a pretty clear cut reason to give it.

 

[Sodapop]

Right and wrong, the more people you can prevent from being intubated and kept off of a ventilator, the better. Narcan should ahve been used, a call review at our system would have been generated for something like this if Narcan was not given since it is a pretty clear cut reason to give it.

Agreed. I would have gone with Narcan initially but if the patient already had a tube in place I would have thought twice to prevent a patient from pulling out an airway and possibly causing more trauma. So I can see where on arrival at the ER that Narcan may not have been considered.

 

[Fish]

Agreed. I would have gone with Narcan initially but if the patient already had a tube in place I would have thought twice to prevent a patient from pulling out an airway and possibly causing more trauma. So I can see where on arrival at the ER that Narcan may not have been considered.

Oh, right... I thought, nevermind I misread your post.

No way would I push narcan on a dood whose toob'd

 

[Smash]

Right and wrong, the more people you can prevent from being intubated and kept off of a ventilator, the better. Narcan should ahve been used, a call review at our system would have been generated for something like this if Narcan was not given since it is a pretty clear cut reason to give it.

As this has been resurrected: this call also would have generated a review in my system, but only if I gave a drug that is not indicated for a problem that doesn't exist. That is unlikely to happen though, because I treat what I can reasonably deduce to be wrong with the patient. I don't treat pinpoint pupils. Maybe that is just me, but then I was educated to practice medicine.

 

[Fish]

As this has been resurrected: this call also would have generated a review in my system, but only if I gave a drug that is not indicated for a problem that doesn't exist. That is unlikely to happen though, because I treat what I can reasonably deduce to be wrong with the patient. I don't treat pinpoint pupils. Maybe that is just me, but then I was educated to practice medicine.

Right, the history and patient presentation screams Narcan.

 

[Handsome Robb]

Right, the history and patient presentation screams Narcan.

+1

It would have been flagged for review here as well. Well most all intubations are reviewed anyways.

 

[Smash]

Right, the history and patient presentation screams Narcan.

The history of not having taken opioids? Oh, ok then I will keep in mind that not having been reported to have had opioids, having no physical evidence of such, and having a couple of symptoms that can be attributed to the drugs the patient has taken, or to a range of other medical conditions rather than opiods means that opiods have been taken.

Good to know, that's a practice changing pearl of wisdom there.

 

[Fish]

The history of not having taken opioids? Oh, ok then I will keep in mind that not having been reported to have had opioids, having no physical evidence of such, and having a couple of symptoms that can be attributed to the drugs the patient has taken, or to a range of other medical conditions rather than opiods means that opiods have been taken.

Good to know, that's a practice changing pearl of wisdom there.

Glad to know I could help learn you something

If this call doesn't scream use of Narcan, well then... I don't know what to tell you. Present this scenario to every ER Doc you see in the Next 30 days and see who they agree with, me or you.

 

[Smash]

It will no doubt be an interesting conversation:

Me: "Doc, if you have a patient with a benzo and atypical antipsychotic overdose, you should give them narcan right?"

Doctor: "Ahhhh.... what?

Me: "You know, someone who has taken too many benzos and seroquel, narcan will fix them right up won't it?"

Doctor: "Sorry, are you f**ked in the head? Has somebody put you up to this, or are you actually retarded?"

Me: "No, really, narcan is the go to drug in situations that have no history of opioid overdose, but some CNS depression: some dude on the interwebs who calls himself a paramedic told me so"

Doctor (backing away slowly towards the duress button) "Sure, whatever you say buddy..."

Me: "Hey guys, are you security? Cool! Is that a Taser? Neat, I've always wanted to AAAAAHHHHHHHHHHHHHH!"


I will actually do that, I'm back on nights this week, so I will genuinely go ahead and see what the ER docs say. I will head up to ICU and ask the ICU docs as well.

Do you seriously go through life in EMS just picking a symptom and giving a drug that may be completely inappropriate? I know EMS in the US, broadly speaking, is in a :censored::censored::censored::censored: state, but that really scares me. Describe for me how this call "screams narcan", because I really am struggling to see it.

 

[Handsome Robb]

Pinpoint pupils, respiratory distress/arrest, ALOC, suspected OD of pharmaceuticals + a history of previous attempts I don't see why it would be inappropriate to trial narcan. There's no opioids in the house but who's to say he didn't have them in the wrong container seeing as he could very well buy them on the street. Opioids are a commonly abused drug and pretty readily available illegally.

I see your point Smash but still. Plus if you deliver the question to a doctor like that how do you suspect to get the time of day from them? You'd be leading them with your questions.

 

[Fish]

It will no doubt be an interesting conversation:

Me: "Doc, if you have a patient with a benzo and atypical antipsychotic overdose, you should give them narcan right?"

Doctor: "Ahhhh.... what?

Me: "You know, someone who has taken too many benzos and seroquel, narcan will fix them right up won't it?"

Doctor: "Sorry, are you f**ked in the head? Has somebody put you up to this, or are you actually retarded?"

Me: "No, really, narcan is the go to drug in situations that have no history of opioid overdose, but some CNS depression: some dude on the interwebs who calls himself a paramedic told me so"

Doctor (backing away slowly towards the duress button) "Sure, whatever you say buddy..."

Me: "Hey guys, are you security? Cool! Is that a Taser? Neat, I've always wanted to AAAAAHHHHHHHHHHHHHH!"


I will actually do that, I'm back on nights this week, so I will genuinely go ahead and see what the ER docs say. I will head up to ICU and ask the ICU docs as well.

Do you seriously go through life in EMS just picking a symptom and giving a drug that may be completely inappropriate? I know EMS in the US, broadly speaking, is in a :censored::censored::censored::censored: state, but that really scares me. Describe for me how this call "screams narcan", because I really am struggling to see it.

The conversation would go nothing like that, infact I did you a favour. I printed out the OPs scenario, presented to the ER Docs on lastnight and wouldn't you know it, they all said you'd be crazy to not give Narcan before attempting intubation. If I recall you the only person on this thread who disagrees, also I am friggin right. The OP posted this thread because they intubated a patient without giving narcan when it was indicated and got crap for it, that is why he posted it on here. So, how are you going to legitimately argue a point with me when it turns out I am right that the patient needed Narcan?

For you to say after reading this scenario that you fail to see how he needs narcan is scary. Your being tunnel visioned into thinking just because benzos are all that it is "known" that the patient took, well then must be all that he has in his system. Dude has a known drug history, pin point pupils, ALOC enough to want to intubate, decreased resp. rate. It is known that he has already taken a bunch of benzos, Medic units in the US don't carry ramazicon for benzo overdoses(Yes I amfriggin aware Narcan doesn't touch Narcotic overdoses) But what I am saying, is I would still push narcan all day every day on this patient because he is unresponsive and unable to give you a full history and whith what he is presenting with tells me there is possibly more to this. And guess what? I would be right all day every day if I did push Narcan, how do I know? Because that is why the OP posted this thread, he wanted our opinions on a patient that they did not give narcan to that they should of and once they got to the ER, they quickly found out why they should of given Narcan.

Also, if you ever asked questions in the way that you just posted. Well then of course YOU are going to get the answer YOU were looking for. Hand them a print out of the scenario as written by the OP, and let them decided without your opinion.

nobody disagrees that this patient obviously has ingested Benzos and anti-pshycotics, but that is not the reason for the Narcan in this particular patient.

 

[Sodapop]

Well said Fish

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[Melclin]

I would find this a difficult situation.

The two things that bother me here are down time and losing the ability to tube this guy.

Downtime: We have no idea how long he's been down for. I would have thought there was a pretty damn good chance of hypoxic brain injury here. In that case, we wanna keep down, not bring him up. I see this as being a similar scenario to junkie x crashing his car on the way home from a heroin enthusiast convention. GCS 6-10, head injury, pinpoint pupils, resp depression. That guy is not getting narcan. Not a chance. I think you can make a decent argument that this is a similar situation.

The tube: You narc this guy and he comes good? Well problem solved. But what if he doesn't? What if he doesn't blink an eyelid. Now you need to tube him and you can't provide proper analgesia. Whats worse is if he does come up a little, combative but altered with a hypoxic brain injury, or polypharm OD with opiates and other things, then you have a nasty situation.

The way I see it is that narcan is for uncomplicated opiate overdoses. Low chance of hypoxic brain injury, nil involvement of other substances with no other signs of illness/injury (aspiration, head injury etc). This guy has almost certain poly pharmed himself, so already narcan is low on my list of things to do, and there is a reasonable chance of hypoxic brain injury. Add to that, the fact that there isn't actually any evidence of opiate ingestion. I'd say no to narcan. Wait for Intensive care to turn up, if they wanna tube him, then great, I haven't ruined their party. If they reckon narcan is worth a shot, then that's their choice.

I've had a couple of similar pts most of whom got narcan at some stage with varrying degrees of success. Its a judgement call, as always.

 

[Fish]

I would find this a difficult situation.

The two things that bother me here are down time and losing the ability to tube this guy.

Downtime: We have no idea how long he's been down for. I would have thought there was a pretty damn good chance of hypoxic brain injury here. In that case, we wanna keep down, not bring him up. I see this as being a similar scenario to junkie x crashing his car on the way home from a heroin enthusiast convention. GCS 6-10, head injury, pinpoint pupils, resp depression. That guy is not getting narcan. Not a chance. I think you can make a decent argument that this is a similar situation.

The tube: You narc this guy and he comes good? Well problem solved. But what if he doesn't? What if he doesn't blink an eyelid. Now you need to tube him and you can't provide proper analgesia. Whats worse is if he does come up a little, combative but altered with a hypoxic brain injury, or polypharm OD with opiates and other things, then you have a nasty situation.

The way I see it is that narcan is for uncomplicated opiate overdoses. Low chance of hypoxic brain injury, nil involvement of other substances with no other signs of illness/injury (aspiration, head injury etc). This guy has almost certain poly pharmed himself, so already narcan is low on my list of things to do, and there is a reasonable chance of hypoxic brain injury. Add to that, the fact that there isn't actually any evidence of opiate ingestion. I'd say no to narcan. Wait for Intensive care to turn up, if they wanna tube him, then great, I haven't ruined their party. If they reckon narcan is worth a shot, then that's their choice.

I've had a couple of similar pts most of whom got narcan at some stage with varrying degrees of success. Its a judgement call, as always.

You give Narcan and still feel you need to intubate? Well then I would use Succs and a Benzo to Sedate. Since Narcan does not effect Benzos...

I understand your point, but also it made me think....... How many Narc ODs have I been on(lots I used to work in the Heroin Capital) and out of all of those how many of them did I know there down time, if I had to guess like 20% maybe? Still we gave Narcan, and still an ER Doc would have given Narcan. I have brought in a few Poly Pharm patients as well that I in no way suspected had taken any Narcotics, and depending on the Doc I have seen them administer Narcan as an attempt to rule some stuff out while they wait for a tox screen.

 

[Fish]

The conversation would go nothing like that, infact I did you a favour. I printed out the OPs scenario, presented to the ER Docs on lastnight and wouldn't you know it, they all said you'd be crazy to not give Narcan before attempting intubation. If I recall you the only person on this thread who disagrees, also I am friggin right. The OP posted this thread because they intubated a patient without giving narcan when it was indicated and got crap for it, that is why he posted it on here. So, how are you going to legitimately argue a point with me when it turns out I am right that the patient needed Narcan?

For you to say after reading this scenario that you fail to see how he needs narcan is scary. Your being tunnel visioned into thinking just because benzos are all that it is "known" that the patient took, well then must be all that he has in his system. Dude has a known drug history, pin point pupils, ALOC enough to want to intubate, decreased resp. rate. It is known that he has already taken a bunch of benzos, Medic units in the US don't carry ramazicon for benzo overdoses(Yes I amfriggin aware Narcan doesn't touch Narcotic overdoses) But what I am saying, is I would still push narcan all day every day on this patient because he is unresponsive and unable to give you a full history and whith what he is presenting with tells me there is possibly more to this. And guess what? I would be right all day every day if I did push Narcan, how do I know? Because that is why the OP posted this thread, he wanted our opinions on a patient that they did not give narcan to that they should of and once they got to the ER, they quickly found out why they should of given Narcan.

Also, if you ever asked questions in the way that you just posted. Well then of course YOU are going to get the answer YOU were looking for. Hand them a print out of the scenario as written by the OP, and let them decided without your opinion.

nobody disagrees that this patient obviously has ingested Benzos and anti-pshycotics, but that is not the reason for the Narcan in this particular patient.

I made a typo when I said "Narcan doesn't work on Narcotics" I ment Narcan doesn't touch Benzos.

 

[Smash]

If I recall you the only person on this thread who disagrees, also I am friggin right.

You'll have to do better than logical fallacies. Also: ego much?

The OP posted this thread because they intubated a patient without giving narcan when it was indicated and got crap for it, that is why he posted it on here. So, how are you going to legitimately argue a point with me when it turns out I am right that the patient needed Narcan?

Except not:

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.

An unconnected Dr (doctor of what?) and a medic student opined that they should have given narcan. That doesn't sound like getting crap to me. The fact that no narcan was given by the hospital at any stage suggests that the decision to withhold narcan was correct in the eyes of the treating physicians also.

For you to say after reading this scenario that you fail to see how he needs narcan is scary. Your being tunnel visioned into thinking just because benzos are all that it is "known" that the patient took, well then must be all that he has in his system.

Indeed I do treat on what I know, or what I can reasonably conclude. I cannot reasonably conclude that this patient has had an overdose of opioids. I can make suppositions all day long, but it doesn't help in the management of patients. The presence of pinpoint pupils alone is hardly definitive for opioid overdose.

I'll posit another scenario: 65 year old female, history of hypertension, hypercholestremia, AF, osteoarthritis. Found unresponsive in bed, HR 50, BP 90/50, resp rate 6, pupils pinpoint, GCS 3 and peripherally cyanosed. Do you give narcan?

Dude has a known drug history, pin point pupils, ALOC enough to want to intubate, decreased resp. rate. It is known that he has already taken a bunch of benzos, Medic units in the US don't carry ramazicon for benzo overdoses(Yes I amfriggin aware Narcan doesn't touch Narcotic overdoses) But what I am saying, is I would still push narcan all day every day on this patient because he is unresponsive and unable to give you a full history and whith what he is presenting with tells me there is possibly more to this. And guess what? I would be right all day every day if I did push Narcan, how do I know? Because that is why the OP posted this thread, he wanted our opinions on a patient that they did not give narcan to that they should of and once they got to the ER, they quickly found out why they should of given Narcan.

They found out by the ER not giving narcan as well and the pt being sent to ICU for the polypharmacy overdose? I think you might need to re-read the thread, particularly the original post. The OP has never stated that he got in trouble for anything. Personally I think they should have got in trouble for poor airway management attempting to intubate the patient, but it sounds as if they may be bound by protocol for that anyway.

nobody disagrees that this patient obviously has ingested Benzos and anti-pshycotics, but that is not the reason for the Narcan in this particular patient.

So even if I were to humour you, and admit that, despite the lack of any compelling evidence to support the theory, there is a chance that opioids have been taken: what can you reasonably expect to occur to happen when you give narcan to a polypharmacy overdose?

I have brought in a few Poly Pharm patients as well that I in no way suspected had taken any Narcotics, and depending on the Doc I have seen them administer Narcan as an attempt to rule some stuff out while they wait for a tox screen.

Doctors practicing bad medicine is hardly an excuse for us practicing bad medicine. I've seen doctors refusing to give analgesia to patients with abdo pain, putting non-rebreathers on normoxic chest pains, neglecting to give sedation and analgesia after RSI... the list goes on.

 

[boingo]

I'll posit another scenario: 65 year old female, history of hypertension, hypercholestremia, AF, osteoarthritis. Found unresponsive in bed, HR 50, BP 90/50, resp rate 6, pupils pinpoint, GCS 3 and peripherally cyanosed. Do you give narcan? QUOTE]

Other than your reduced ability to manage pain w/opiate analgesia, what would be the down side? I had a similar case about a year ago, with added hx of depression, no opiates in residence. A trial of Narcan reversed the event, pt woke and admitted to taking a large amount of Oxycodone.

The other way that call would have played would have been an un needed intubation, CT scan and ICU admit, although with the ability to add Fentanyl or your opiate of choice to round out her analgesia/sedation.

Not saying the other course of action would be "wrong" per se, it's just a different approach.

Although us American medics are a pack of retards, the physician level of providers for the most part are not. FWIW