Nonrebreather with an Oral Airway?

[MrBrown]

...An LMA does not have aspiration protection to my knowledge...

You are correct; they are not what I'd recommend but it is all we have if an officer who can intubate is not onboard.

Depending on the distance to the hospital it might be worth calling for backup if it would be possible to intercept them faster than we could deliver the patient to the ED.

 

[Smash]

Let me start by saying...I really hate Narcan. I don't like dealing with seizing, combative, or puking junkies. That said, if my options are intubating someone (EtOH or no, a GCS of 3 is a candidate) or try Narcan, I'd give the meds a shot before I tubed them.

I've given narcan to opiate overdoses hundreds, if not thousands of times in my career. I have never had anyone come up seizing, swinging or puking. If it is done properly with due care for the underlying problems the patient has, it is not an issue.

I'm just amazed that in a patient who has no evidence of opiate OD, but is simply unconscious, (presumably from the ETOH) there are MDs who want their medics pushing narcan, and medics who will happily push it.

What is supposed to happen when you give narcan to the drunk?

I had an interesting case along these lines just last week. Male patient, 40s, no previous history, no meds no allergies. Called for suspected cardiac arrest. Arrived to find FD first responders and an ILS crew on scene with what was described as a methadone overdose. ILS crew attempting to ventilate and were just about to give the narcan. I stopped them.

Found out some more history, which included 2 day polypharmacy bedner that included methadone but also included every other drug one person could reasonably get their hands on. Patient has been down for a long time (5 hours+), is cyanosed, EtCO2 of 90, SpO2 of 88 whilst being bag and mask ventilated, chest full of crap, belly full of more crap and an intact gag.

We carried out an RSI, using fentanyl, versed and sux, followed by sedation of versed and morphine when he started fighting the tube. We eventually had to paralyse him to control ventilations adequately as sedation alone was not enough and we were wrecking his BP.

Now, we could have gone ahead and pushed the narcan I suppose, but all that would have done is made our lives much more difficult and had no effect on any of the other problems the patient had.

Blindly pushing narcan to anyone without a decent rationale is just plain dumb, and an embarrassment to our 'profession'

 

[Akulahawk]

Given that specific case... I'd have to have to say "good call" for holding off on the narcan.

 

[AZFF/EMT]

Agree 100% about the narcan. Yet if we dont on unconscious patients we risk getting talked to for not following protocol. Husband said she didn't drink that much and does take pain meds and psych meds.

 

[AZFF/EMT]

I thought about intubating but just didnt feel it was the right move. Guess I coulda got burned byu not securing the airway but it worked out that time. Pt was breathing 16-18 times a min etco2 37, sao2 99-100%, no snoring, yes I do understand the aspiration risk and I paid very close attn to her airway.

Also I follow my protocols, I have seen what has happened to too many medics around here when they choose to assume things and not give a certain drug here and there. There was no strong reason to suspect an opiate issue but with the info I had technically in my system I MUST give narcan.

Oh earlier ?'s . BGL 112, meds unknown except pain, RA meds and psych meds. Alcohol estimate was 6-7 beers which never puts her in this condition.

 

[emtjack02]

Glad that it all worked out! Did you ever found out what was the cause of the ALOC? I suppose one could argue that if you were able to "r/o ETOH" that there should be a more of a concern of the ALOC..

 

[AZFF/EMT]

Nope not yet, RN was supposed to give me a call and let me know what her labs and blood alcohol levels were but they were swamped and she never did. I havent been back into the ER the past 2 shifts because I am on my engine rotation now. If I am able to find out I will post it.

 

[Brandon O]

Personally I like the NPA and if no trauma, place in recovery position and monitor the airway with a NRBM if only oxygen therapy is needed.

What effect would a basic airway have on a patient in recovery position? Shouldn't their tongue be clear anyway?

 

[SurgeWSE]

I've given narcan to opiate overdoses hundreds, if not thousands of times in my career. I have never had anyone come up seizing, swinging or puking. If it is done properly with due care for the underlying problems the patient has, it is not an issue.

I'm just amazed that in a patient who has no evidence of opiate OD, but is simply unconscious, (presumably from the ETOH) there are MDs who want their medics pushing narcan, and medics who will happily push it.
...

Blindly pushing narcan to anyone without a decent rationale is just plain dumb, and an embarrassment to our 'profession'

Glad your experiences have been nicer than mine, but I've also given Narcan in carefully titrated doses to many opioid comas in my career I've had plenty of them projectile vomit on the nearest wall or come absolutely unglued. The fact is, you can pay attention the other underlying problems and use all the due care in the world, and sometimes they're still going to have a violent reaction.

As for the case study you presented, I agree completely that RSI is more appropriate given the situation. You weren't simply controlling an airway that was in danger from the coma, he has obviously aspirated copious amounts of crap and has, by history, a polypharmacological medley in him, so there is no way to predict the effect removing the opioid sedation would produce.

I fail to see how giving Narcan to the patient in the original case is either "blindly pushing" or "embarrassing". I think it is perfectly reasonable to use Narcan in a coma of unknown origin if there is no obvious reason no to.

 

[Smash]

I fail to see how giving Narcan to the patient in the original case is either "blindly pushing" or "embarrassing". I think it is perfectly reasonable to use Narcan in a coma of unknown origin if there is no obvious reason no to.

The OP explained why he gave the narcan in such a situation, which is a sad indictment on the disdain with which his medical director clearly holds his medics, even though the OP him/her self does not necessarily agree with that course of treatment.

If the Pt had no reported history of taking opiates, no environmental evidence existed of having taken opiates and examination revealed no signs of opiate overdose, then it is blindly pushing narcan for no good reason.

I find it embarrassing that in this day and age paramedics are apparently unable (or considered unable) to perform a simple examination of a patient, that in concert with a hx, and a size up of the environment around them, would reveal something like the presence or absence of an opiate overdose.

However I find it much more embarrasing that my erstwhile peers and colleagues continue to defend such cookbook approach to medicine; meanwhile every other thread in forums such as these trumpets the need to be recognized as a 'profession' and bemaons the terrible tragedy that we are not so recognized.

 

[Akulahawk]

Smash... I can understand your feeling towards "cookbook" medicine... I've met more than a couple staunch cookbook medics. The problem stems from an "Unknown/Unconscious" type protocol that requires that Narcan be given. Remember, deviation from those protocols requires a base order. While a good medic should be more than capable of determining when a patient needs Narcan... the protocol is (rightly or wrongly) written for the lazy medic.

In an environment where the Base will back up the protocols... (by refusing the request not to give narcan needlessly), and I ultimately refuse to follow orders, I would very likely end up being the subject of a disciplinary hearing...

Cookbook medics rely on those protocols, the protocols are written for the lazy/cookbook medic, the base reinforces the protocols, and deviation from them might be bad...

On the whole, at the EMS Agency level, cookbook medicine is encouraged... at least out here.

I have much disdain for cookbook medics... they allow us to get into the above cycle...

 

[Smash]

I understand poorly informed Medical Directors (or possibly well informed MDs I suppose) refusing to allow medics to make sensible decisions.

I understand why the OP was required to push narcan (but I don't agree that he should have to).

What I don't understand is why some medics themselves seem to think that the random administration of drugs to patients is in anyway useful, professional, safe or effective. I give medications when there is an indication to give them; I don't just give them because there are no contraindications.

EMS providers constantly complain that we aren't seen as "professionals". Yet here we are (some at least) defending sloppy, unthinking, contradictory cookbook EMS that does nothing to benefit our patients, let alone anything to enhance our standing in the medical world, by demonstrating that we are nothing better than trained monkeys with a box full of drugs.

Let me be clear, however, that I understand the reason behing AZFF/EMT giving the narcan, this is not a rant against him/her. It is a rant against those who do nothing to try and change this situation and even defend the practice.

I don't know what sort of service AZFF workd for, but I would hope that he/she would be able to approach the MD with a reasoned case not to be providing substandard, protocol bound care. This too may be a pipedream (although it works in my service) however, nothing ventured, nothing gained.

 

[emtjack02]

For one to change the situation then I'd have to see something wrong with it. Blindly following orders or protocols is a problem. However, that is not the case with narcan. I do now see how giving it for a unc/unk is a problem. Medicine is generally the game of r/o. Why not r/o something that can be reversed quickly.

 

[Smash]

Sure, why not, I guess if you can't assess a patient then you should just go with ruling things out.

Can't rule out benzo OD, better push some flumazenil. Can't rule out asthma, better get those bronchodilators and steroids on board. Can't rule out cardiac arrest if we can't assess a patient properly, so lets draw up that epi and give them a tickle with the jumper cables.

Boy this medicine game sure is fun!

It would be nice if a few more people could ride out with some of the Australian medics I've met over the years. No OLMC; wide ranging protocols that can be varied so long as there is rationale; extremely high survival rates from cardiac arrest; excellent success rates for intubation; RSI for all air and road based medics; cutting edge research carried out by and for paramedics; representation on medical standards boards for their services; the ability to drive change themselves for the good of the patient and the service and ultimately the standing; respect and recognition that comes with being professionals along with pay and conditions that rival nurses. Hell, in at least one state it takes RNs 2 years to become a paramedic, not the other way round!

The other thing that is noticeable is no whining and moaning about not being recognized, no excuses, no half-baked protocols that assume no ability to assess or treat. Simply put, they get on and do it, do it well and are recognized for it.

 

[Akulahawk]

Smash: generally agreed.
emgjack02: Narcan shouldn't be given blindly. One of the issues with Narcan is that because it blocks opioid receptors, once given, if you need to provide pain control later on, that pain control must be given via a non-opiate until the Narcan is metabolized. If your assessment does not show that the patient is on an opiate narcotic OD, why give a medication that isn't needed?

On the other hand, if your assessment shows signs of a narcotic OD... be very careful about administering the drug... it can have some really nasty effects if you blindly follow protocol and administer it... too fast.

Smash brings op another point: why not blindly give flumazenil for that possible benzo overdose? Oh, that's right... flumazenil can precipitate seizures... and what do we use to quiet them down? Oh... benzodiazepines...

You don't administer a medication to R/O a condition. You administer to confirm and treat a specific condition that your assessment indicates is the problem.

 

[emtjack02]

Smash: generally agreed.
emgjack02: Narcan shouldn't be given blindly. One of the issues with Narcan is that because it blocks opioid receptors, once given, if you need to provide pain control later on, that pain control must be given via a non-opiate until the Narcan is metabolized. If your assessment does not show that the patient is on an opiate narcotic OD, why give a medication that isn't needed?

On the other hand, if your assessment shows signs of a narcotic OD... be very careful about administering the drug... it can have some really nasty effects if you blindly follow protocol and administer it... too fast.

Smash brings op another point: why not blindly give flumazenil for that possible benzo overdose? Oh, that's right... flumazenil can precipitate seizures... and what do we use to quiet them down? Oh... benzodiazepines...

You don't administer a medication to R/O a condition. You administer to confirm and treat a specific condition that your assessment indicates is the problem.

Good points. While agreed it's not the best practice to give meds to r/o, however, we do not live in a perfect world. Can't say I have ever pushed narcan in the field so I can only imagine some of the side effects people see.

 

[Akulahawk]

Good points. While agreed it's not the best practice to give meds to r/o, however, we do not live in a perfect world. Can't say I have ever pushed narcan in the field so I can only imagine some of the side effects people see.

Biggest side effect... your patient can get REALLY pissed at you and can become EXTREMELY agitated... possibly combative even... and guess who will be on the receiving end? You.

I'm not exactly a fan of protocols that require a specific cocktail of medications to give to the unknown/unconscious patient. Most of the protocols I've seen recently specify that ONLY in a patient with a suspected opiate OD should narcan be administered...

 

[arsenicbassist]

Biggest side effect... your patient can get REALLY pissed at you and can become EXTREMELY agitated... possibly combative even... and guess who will be on the receiving end? You.

I'm not exactly a fan of protocols that require a specific cocktail of medications to give to the unknown/unconscious patient. Most of the protocols I've seen recently specify that ONLY in a patient with a suspected opiate OD should narcan be administered...

Akulahawk, have you seen any with a glucose check to determine need for thiamine vs. dextrose vs. narcan? Mine has a pretty lengthy process to get to Narcan and not to use it as a r/o. But, as was said previously, we don't live in a perfect world. We used to just give em the 3 punch combo, but that's being phased out slowly.

 

[arsenicbassist]

I've seen guys load a pt with Narcan and it's NOT a good sight. If you use it blind, go low....around 0.4mg....and sloooooooooooow. Akulahawk has the right idea on the benzo OD....careful with Flumazenil, as it seems to be veeeeeeeeeeeery touchy. Aggressive treatment can result in aggressive complications.

 

[arsenicbassist]

EVERYONE can look at things in medicine as three seperate partsl
1. Things that help
2. Things that hurt
3. Things that don't matter

Don't do the last two and we should all be fine. HAHA. And on cookbook medicine...advances weren't made by confining oneself to cookbook or algorithm medicine.