Narcan, or Not.

Phillyrube

Forum Crew Member
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Ok, watching Nightwatch on AETV. First call, overdose. Cool. Get him in the box, O2, pulseox. EtCO2., Fire department bagging guy. Start an IV, and "Narcan is in". Next second guy is up, with like 8 people trying to hold him down. Blood from the pulled out IV sprays everyone. Finally guy calms down after being restrained every which way.

Sound familiar? How do you handle it? Our protocols call for 2-4 mg narcan IV or IN. With the advent of CO2 monitoring, do we need to throw the entire dose on the patient? We've been giving the patient 1-2 mg narcan, and monitor. If the numbers are good, let them sleep. Now, we gotta train the cops not to be so quick with their INs. Had a couple get pissed cause the woke up the pateint, who is now combative, and I made them ride in with us (helps that I was also a PD supervisor).

What say you?

Carry on, boys.
 

NPO

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2-4mg IV is probably way more than you need. I give 0.5mg IV or 2mg IN to start. I've never had a patient wake up angry, vomiting or combative.

Also, giving it slowly is a big deal too.
 
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DrParasite

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I live for the day where I get to give 2 mg of narcan and the dead will rise..... It's on my bucket list....

I've seen the combative narcan response once, and the situation was exactly as you drivingde.. . Most of the time they aren't that bad.

I do think slowly waking a person up with narcan while assisting respirations with a bvm is better than giving the the whole dose hard and fast, there's something to be said about thrm walking down the steps or out the door under their own powera control and breathing in their own.
 

cprted

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I'm fully onboard with @NomadicMedic and @DrParasite. There is absolutely no reason to slam 2mg IV into anyone as a first line treatment. Once you've established good ventilations, the emergency is over. Take your time and wake them up slowly.

Establish good ventilations with BVM. Just bag them for a minute or two to correct hypoxemia and hypercapneia. Then I usually start with 0.4-0.8mg of Naloxone IM. 80% I don't have to give a second dose. Very rare to have anyone come up combative. Usually they start to open their eyes, we pull the bvm away and tell them to take their OPA out. That's how the overwhelming majority of my OD calls go.
 

CCCSD

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Dr P, for your amusement:

On an OD call years ago.

Baby momma: “ He’s dead! He’s dead!”

(Me pushing Narcan, doing PM stuff) Pt wakes up, starts getting grabby. Crowd gasps, “oooohhhhh...”

Baby momma: “He’s alive! Oh Lord! Thank you Baby Jesus,”

Me: “Don’t thank The Lord, Lady. Thank me and DuPont Chemicals.”

Baby momma: “Wha’?”

I do miss it at times...
 

NPO

Forum Deputy Chief
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Dr P, for your amusement:

On an OD call years ago.

Baby momma: “ He’s dead! He’s dead!”

(Me pushing Narcan, doing PM stuff) Pt wakes up, starts getting grabby. Crowd gasps, “oooohhhhh...”

Baby momma: “He’s alive! Oh Lord! Thank you Baby Jesus,”

Me: “Don’t thank The Lord, Lady. Thank me and DuPont Chemicals.”

Baby momma: “Wha’?”

I do miss it at times...
Reminds me of that scene from Mother Jugs & Speed
 

Bullets

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2mg IN and wait until they wake up. I am loathe to start a line on opiod ODs since i have IN drugs and a BVM
 

jwk

Forum Captain
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I am light years out of EMS and treating OD. But the amount of Narcan used, by my practice, is huge! As a couple have noted, if you're ventilating and oxygenating your patient (I assume SaO2 being used), your apneic emergency has passed. You can always give more Narcan if needed. Remember that CO2 has anesthetic properties at higher ranges, which in an apneic patient is quite possible. It takes a little time to get the EtCO2 down.

https://www.openanesthesia.org/carbon_dioxide/
 

johnrsemt

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Bad thing is with PD having Narcan; most people that are down and not breathing due to OD's are going to be brain dead by the time PD gets there so it won't help a lot.

PT job we give Narcan a lot. ALOT. I try to keep it at 0.2mg per dose, and titrate it; I would rather have to bag a patient during parts of a 120 mile transport than fight them.

Plus Narcan isn't doing by itself. Too many cocktail OD's out there.
 

NPO

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Bad thing is with PD having Narcan; most people that are down and not breathing due to OD's are going to be brain dead by the time PD gets there so it won't help a lot.
That's not actuate.

PD is giving narcan to the "fresh" ODs. The ones with brain damage are usually in cardiac arrest.
 

RocketMedic

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+1 on the polypharm ODs
 

KingCountyMedic

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We will go 0.2 - 0.4 mg to start, IN, IM, IV. Our LEO's carry 4mg nasal spray that gives the entire 4mg in one shot. They are also trained to provide rescue breathing prior to giving the Narcan. Our BLS Fire folks carry 2mg Nasal and are trained to give 1mg and BVM, wait for them to wake up and wait for us. We are dispatched to all overdoses that get IN Narcan from LEO or Fire. We will evaluate, give more if needed, maybe some Zofran if needed etc.
 

johnrsemt

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That is good that some Police Departments are training in rescue breathing and when to do it; and it is good for fresh OD's.
Where I work PT (where we have a major OD problem) we and the PD and fire have about a 100 X 90 mile coverage area. There is 4 fire departments (2 west of our town, and 2 in our town {our town straddles state line and is actually 2 towns, with basically same name}). But we get OD's 40 or 50 miles out on the highways, that may or may not have a crash involved, so the PD gets there faster (120 mph against 80 for us). They give Narcan, and rescue breathing (BVM) but usually doesn't do much.
A lot of times with family members who have Narcan you get the same results unless the family member sees the druggie go down it may be a while before they find the OD, and give Narcan; and they usually don't do rescue breathing. And they think that if they give Narcan that is all that has to happen: No CPR or anything.
Narcan the miracle drug except when it isn't
 

KingCountyMedic

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Our LEO folks are really big on EMS calls, they all have Defib units, trauma kits, Narcan. I've had cops beat us to dozens of CPR calls over the years and they have started CPR, shocked, and achieved ROSC prior to our arrival. Just south of us in Pierce County the Tacoma Fire Department is handing out Narcan on calls to family members when they show up on OD's. I believe they got a grant to do it.
 
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