Narcan Question

[82-Alpha599]

hear is one example from yesterday, but it happens all the time with people I work with.

Get a life alert activation call. on arrival no answer at the door, after a miniute we let ourselves in and see a 75ish y/o female sitting on the couch, alert to painful stimuli only.
no noted trauma
Resps- 16-18 regular non-labored clear bilat
HR-105 irregular
BP- 86/61
skin- pink warm very diaphretic (house probably 85 degrees inside)
SpO2- 96 RA
BGL- 110
pupils 4-5mm sluggish
ECG 3-lead - sinus arrhythmia (not a-fib confirmed by DR at ER)
no med list or family available


initial treatment
O2 NRB
IV 250ml NS bolus started

now someone wanted 2mg narcan IV
i said no because i saw no signs of narcotic OD

then all the sudden the pt woke up AxOx3, stated she felt dizzy then hit her life alert and that was the last thing she remembers.
12-lead obtained without ECG change.
after 350ml pt normotensive, HR 85-100

does every alterd LOC get narcan?
I dont, but we can if we want


second question

combined OD
narcotic, and ______ overdose.
narcan? or supportive treatment?

 

[fyrfyter]

I am still very new to being a paramedic but given the respirations where 16-18 and not slow and shallow Narcan would not have been early at all in my treatment. I could be way off here.

 

[Veneficus]

Coma Cocktail

now someone wanted 2mg narcan IV
i said no because i saw no signs of narcotic OD

then all the sudden the pt woke up AxOx3, stated she felt dizzy then hit her life alert and that was the last thing she remembers.
12-lead obtained without ECG change.
after 350ml pt normotensive, HR 85-100

does every alterd LOC get narcan?
I dont, but we can if we want

Back in the day (probably about 15+ years ago now) There was often a EMS protocol called "Coma of unknown origin" which directed the administration of thiamine, narcan, and d50.

It was based largely on unproven theories that have since been debunked or found to be more adventageous in a controlled setting, as well as being at a time when most EMS services didn't have finger stick glucometers.

Unfortunately not only do many older medics still believe it to be a viable and adventageous practice, I have observed it is still taught under the guise of "the difference between what the book says and what happens in the street."

Professionalism is a long way off.

second question

combined OD
narcotic, and ______ overdose.
narcan? or supportive treatment?

supportive treatment, let the ICU mix meds don't try in the back of a truck.

 

[WTEngel]

Another thing to consider with administration of narcan is what exactly are you trying to achieve?

If I have a high index of suspicion for narcotic OD (which I would not in this case, there is nothing really pointing that direction), I don't necessarily want to bring the patient back around to fully CAO. In fact, really, I want them to be able to maintain their own airway, SPO2, and ETCO2, and that's about it.

I have had partners in the past who advocated "slamming" the narcan in order to ruin the junkie's high, and it almost always ends with a combative, vomiting, dangerous patient.

I point this out because, in your particular case, the patient was supporting her own airway, holding her sats, etc. The only thing that was really out of line was the BP. So there you go...treat the treatable. Bolus was a good choice, and it seemed to do the trick.

In answer to your original question though, absolutely NO, not every patient with altered LOC gets narcan. This is a very cookbook manner of thinking, and has someone pointed out earlier, is probably a result of the old school "coma cocktail" of narcan, thiamine, and d50.

Treat the treatable, do no harm, take away the pain.

TE

 

[Phlipper]

I have had partners in the past who advocated "slamming" the narcan in order to ruin the junkie's high, and it almost always ends with a combative, vomiting, dangerous patient.

Just a student ... but can confirm this one. I had a former employee/friend OD on tar heroin while stopped at a gas station (shooting up in the car). The Para hit him with Narcan and the employee says he "woke up and went nuts", and the guy with him confirmed it was a very bad scene. Not sure that's something I'd want to deal with on top of everything else.

 

[FF-EMT Diver]

I agree with not slamming Narcan to an OD if they can support themselves, however my response to these unknown unresponsive call are as follows

BG? <60 give D50
Pupils? Pinpoint gets Narcan.
Notable excessive ETOH gets Thiamine.

Sounds like your Pt. had a syncopal episode resulting from a drop in BP, coming from what is heard to say. Sounds like y'all did the appropriate tx and everything went well.

 

[zmedic]

Though I agree with the above, I don't think that anyone would fault you for pushing some narcan. Elderly patients are usually on a lot of drugs, if you can't get a good history or drug list it's reasonable to suspect that a painkiller may be one of them.

It wouldn't be the first thing I'd do, but after addressing most of the other causes of mental status changes that you can treat or detect (do a 12 lead, check a finger stick, give fluids etc) a dose of narcan would be reasonable. But not required.

 

[ffemt8978]

Back in the day (probably about 15+ years ago now) There was often a EMS protocol called "Coma of unknown origin" which directed the administration of thiamine, narcan, and d50.

It was based largely on unproven theories that have since been debunked or found to be more adventageous in a controlled setting, as well as being at a time when most EMS services didn't have finger stick glucometers.

Unfortunately not only do many older medics still believe it to be a viable and adventageous practice, I have observed it is still taught under the guise of "the difference between what the book says and what happens in the street."

Professionalism is a long way off.



supportive treatment, let the ICU mix meds don't try in the back of a truck.

We still have that protocol.:wacko:

 

[Veneficus]

We still have that protocol.:wacko:

Do you have one of those 10,000 page protocol books that instead of taking things out, they write an addendum that gets added in?

 

[Aprz]

What about opiate triad (ALOC, inadequate resp., and miosis/pinpoint)? During my EMT ride along, we had what we believe was a heroin OD, however, the gentlement (ha, gentlemen) was still breathing adequately so naloxone wasn't administered (was consider unnecessary to do so) until we handed him over to the hopsital. He was already combative when we picked him up so we got to retrain him (that was an interesting experience for me). I believe the hospital also administered haloperidol (I asked, but I am not sure if I am remembering correctly) to relax him.

I'd say resp is the main thing though. Like WTEngel said, what are you gonna achieve by doing so?

 

[ffemt8978]

Do you have one of those 10,000 page protocol books that instead of taking things out, they write an addendum that gets added in?

No, actually we have some fairly progressive protocols (in some aspects) with a lot of leeway for medics to exercise their judgment. Our protocols are about 100-150 pages total, but we do have a written protocol for epistaxis.

 

[feldy]

Just a student ... but can confirm this one. I had a former employee/friend OD on tar heroin while stopped at a gas station (shooting up in the car). The Para hit him with Narcan and the employee says he "woke up and went nuts", and the guy with him confirmed it was a very bad scene. Not sure that's something I'd want to deal with on top of everything else.

Yes...it can lead to some very unpleasant introductions with your pts. Be prepared and maybe restrain them prior to the narcan push. Also ripping out the iv you have just so beautifully placed is a common one. (Seen it done so many a time)

 

[82-Alpha599]

thanks for confirming my thinking. Sometimes I feel like the idiot when everyone else is against me.

Our protocol for Narcan is 2mg IV/IM/IO. I usually start with 0.4 to 1mg depending on pt size, and give it really slow. only twice have I had to give more than that. One took 8mg, known Heroin OD, and the other 12mg Vicodin.

Even vicodin could be considered a combination OD eh?
(hydrocodone & APAP)

 

[feldy]

8mgs? The pt must of have been quite a large person or a possible frequent flyer of ODs?

 

[jjesusfreak01]

The short answer to your invisible phantom question feldy is...

No, Narcan doesn't have any uses other than treating narcotic problems. Its primary mechanism is binding to opioid receptions. The wikipedia article does mention one other use, in which it can treat patients who have complete insensitivity to pain, but that probably works by the same mechanism.

 

[feldy]

haha yeah i though it was kind of a dumb question but wasnt sure. I read that same thing but that was the first i heard that so i wasnt sure if it was true.

 

[82-Alpha599]

8mgs? The pt must of have been quite a large person or a possible frequent flyer of ODs?

oh yeah about 250lbs all muscle. I was actually very afraid that he would wake up too much and want to fight. thank god he was still lethargic after 8mg

 

[lightsandsirens5]

We still have that protocol.:wacko:

I think that is state wide. We have the same thing, except, out MPD recently pulled thimine, and he is now putting a stop to the whole "coma coktail" idea, thank God.

 

[MrBrown]

Naloxone would not be indicated in this patient simply because there is no evidence of opiod ingestion.

 

[Veneficus]

oh yeah about 250lbs all muscle. I was actually very afraid that he would wake up too much and want to fight. thank god he was still lethargic after 8mg

Narcan also has a shorter 1/2 life than most opioids, sometimes depending on the opioid type/dose, a narcan infusion must be set up in order to keep them from reverting.