I have noticed alot of reluctance to giving narcan in quite a few of the threads and I was just wondering the reasoning behind this. I don't know if I am missing something. I know in my MCA we use narcan all of the time and I have never seen nor heard of any problems from its use other than, vomiting and combativness. I'm a new medic and just want to be sure im getting it all down pat. Thanks.
Narcan question.
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Nervegas
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I believe the point you are discussing is that some medics, myself included, feel that not every unc/unr patient needs the ol' "coma cocktail", that liberal use of narcan just because is a waste and that nothing beats a good pt assessment. I am not against giving narcan in the right situations, but going to it first and often isn't what I would do.
Shishkabob
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The issue? Slamming it, where vomiting and combativeness are the least of your worries. Others include arrythymias and possible arrest from sudden withdrawl.
However, if you push it smartly, there's little reason to be worried, and little reason not to do it for an unconscious of unknown etiology.
However, if you push it smartly, there's little reason to be worried, and little reason not to do it for an unconscious of unknown etiology.
Nervegas
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I would say that those three signs would be a clue to give narcan, not withhold it? I think you meant that they would not give it in those instances? In which case, I would agree with your original point of it being confusing.
MICP
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"titrate"
There is an often forgotten or untaught technique with medication administration called "titration". For those who have taken a chemistry course, we remember doing this as we mixed two chemicals until we saw the desired effect (I understand this is a very loose definition of titration). This is most useful with Narcan administration especially when there is suspicion of polypharmacy, like a patient who has taken a "speed ball", a mixture of morphine or heroin and cocaine.
They have the respiratory depression that needs managed and the pinpoint pupils scream opiate, but the possibility of cocaine being unabated by the CNS depressant can be a concern. So why not give the Narcan in 0.4 mg increments until a rise in the respiratory status?
For those systems where the combative behavior cannot be readily managed pharmacologically, this allows the patient's own medicine (opiates) to keep them chemically sedated while still following the appropriate steps to manage the respiratory depression associated with the opiate itself.
This same principle is applicable with D50, especially in the case of a "mixed bag" of complaints...slurred speech, unilateral weakness, hypertension, but pale, cool, moist...that could be a stroke or hypoglycemia. So you do an accucheck and it comes back at 40. You know all of the associated risks with injecting this hypertonic necrotizing agent in the blood stream of someone have a stroke, especially a hemorrhagic one, but the blood sugar is low.
Give half the amp! Reassess v/s and blood sugar, and if it is normal and symptoms persist, it was also a stroke.
Titrate.
There is an often forgotten or untaught technique with medication administration called "titration". For those who have taken a chemistry course, we remember doing this as we mixed two chemicals until we saw the desired effect (I understand this is a very loose definition of titration). This is most useful with Narcan administration especially when there is suspicion of polypharmacy, like a patient who has taken a "speed ball", a mixture of morphine or heroin and cocaine.
They have the respiratory depression that needs managed and the pinpoint pupils scream opiate, but the possibility of cocaine being unabated by the CNS depressant can be a concern. So why not give the Narcan in 0.4 mg increments until a rise in the respiratory status?
For those systems where the combative behavior cannot be readily managed pharmacologically, this allows the patient's own medicine (opiates) to keep them chemically sedated while still following the appropriate steps to manage the respiratory depression associated with the opiate itself.
This same principle is applicable with D50, especially in the case of a "mixed bag" of complaints...slurred speech, unilateral weakness, hypertension, but pale, cool, moist...that could be a stroke or hypoglycemia. So you do an accucheck and it comes back at 40. You know all of the associated risks with injecting this hypertonic necrotizing agent in the blood stream of someone have a stroke, especially a hemorrhagic one, but the blood sugar is low.
Give half the amp! Reassess v/s and blood sugar, and if it is normal and symptoms persist, it was also a stroke.
Titrate.
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NomadicMedic
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I find it amazing that more medics don't practice the "titrate until effect is reached" rule. I like to draw my Narcan up in a flush and just infuse it bit by bit until I see an increase in respiratory drive. In many cases it doesn't even take the 0.4mg that I've drawn up. The same with D50 and, in some select cases, morphine.
give em 0.5 mg, just enough to get their respirations up, keep em happy sleeping, and avoid the projectile vomiting =), if respirations go below normal range, hit em with another 0.5mg. And if you hate the ER staff, push the rest to bring em back and leave em with some nice cleaning up to do. 
NomadicMedic
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And if you hate the ER staff, push the rest to bring em back and leave em with some nice cleaning up to do.
I hope you're kidding.
18G
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give em 0.5 mg, just enough to get their respirations up, keep em happy sleeping, and avoid the projectile vomiting =), if respirations go below normal range, hit em with another 0.5mg. And if you hate the ER staff, push the rest to bring em back and leave em with some nice cleaning up to do.
Usually Narcan is given in 0.4mg increments (based on standard rule). I've given it in 0.2mg increments as an attempt to not cause complete blockade of the opiate I had given as ordered for pain management. It wasn't successful. With 0.4mg pt. was fully aroused and back with level 7 pain. Fentanyl did work to take some of the edge off though post-Narcan.
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NomadicMedic
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In overdoses with respiratory depression, I draw up 0.4 in a 10ml flush and titrate the administration to an increase in respiratory drive, not to being fully conscious.
If you're pushing 2mg to be a hot shot or "punish" the PT for overdosing, you should have your hand slammed in a door. It's inexcusable and piss poor patient care.
If you're pushing 2mg to be a hot shot or "punish" the PT for overdosing, you should have your hand slammed in a door. It's inexcusable and piss poor patient care.
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Had a hyrocodone and morphine OD of unknown amount a few months back. He got 6mg naloxone pushed IV with only mild increase in respirations before we realized he also had 6 fentanyl patches on his butt 0_o. Tried to titrate the first bolus, but it ended up not even touching it. He ended up getting intubated...
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give em 0.5 mg, just enough to get their respirations up, keep em happy sleeping, and avoid the projectile vomiting =), if respirations go below normal range, hit em with another 0.5mg. And if you hate the ER staff, push the rest to bring em back and leave em with some nice cleaning up to do.
Something tells me "not kidding"...
There's no way I'd ever want to push 2 mg IV naloxone or even 0.5mg and then 1.5 mg later just to be spiteful. Doing that is absolutely hateful at best. I might do slow IV titration to effect and perhaps later deep IM of the balance for a much slower release of the drug, but NEVER would I even think about slamming in some naloxone just to make anyone's day that much worse...
jjesusfreak01
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Didn't have enough Narcan on the truck for that guy, did you?
usafmedic45
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I've never been prouder of you, young Padawan. LOL
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Lol nope, not quite
We stopped at the 6mg; I think we had two more prefills left. The trucks on the west side here carry almost twice that 
the_negro_puppy
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We have no choice but to give 1600 mcg of naloxone when we use it. That being said, i''ve never used it; opioid ODs are rare here. No huge heroin scene either.