Routine Narcan Use

[NPO]

The Carfentanil memo? That drug should present with definite signs of an opioid OD if that's the case; it's essentially a hybrid synthetic opioid that may not even respond to Narcan (definitely indicated) with our short metro ETA's.

As far as the 1 mg x 2? I do 0.5 mg titrated to effective breathing (improvement). We don't need to give the whole lot almost all of the time when giving it, which TMK is also written in our county protocols. All good though, live and learn.

On another note, hopefully they can get the AMLS course up and running again. I highly recommend for any new (generalizing) paramedic that does not have it. Just bases on the differentials they throw at you alone helps build on critical thinking skills in the field.

Just my $0.02 though.

I've texted L-5 about that class several times.

Sent from my SM-G935T using Tapatalk

 

[VentMonkey]

I've texted L-5 about that class several times.

Sent from my SM-G935T using Tapatalk

PM sent.

 

[Rialaigh]

.5mg at a time titrate to adequate respirations in suspected narcotics overdose.

That said we are now trying out narcan, alert and oriented, 30 minutes total scene time with several sets of vitals, no other complaints, refusal. I'm not advocating this for all patients but for your uncomplicated narcotics overdose it does seem a bit silly to take them to the ER so the ER can wake them up and obtain a refusal. Obviously with intentional overdoses, overdoses couples with large amounts of ETOH, or other issues that complicate waking them and obtaining a refusal we prefer to titrate to respirations

 

[Carlos Danger]

.5mg at a time titrate to adequate respirations in suspected narcotics overdose.

That said we are now trying out narcan, alert and oriented, 30 minutes total scene time with several sets of vitals, no other complaints, refusal. I'm not advocating this for all patients but for your uncomplicated narcotics overdose it does seem a bit silly to take them to the ER so the ER can wake them up and obtain a refusal. Obviously with intentional overdoses, overdoses couples with large amounts of ETOH, or other issues that complicate waking them and obtaining a refusal we prefer to titrate to respirations

That is interesting and a bit surprising, considering how risk-averse we are in medicine in general and in EMS specifically.

It seems quite unlikely that someone would re-narcotize after being completely alert and oriented, especially if it didn't take a ton of narcan to get them that way. That said, the duration of narcan is only 30-60 minutes, and the duration of some of the most commonly abused opioids is much longer than that. So in theory at least, it is entirely possible for someone to need a second or even third dose of narcan.

 

[ERDoc]

I don't believe in just throwing meds at things in a "blanket" sense. I don't know who lurks in these forums so I can at the post rather timidly. I've been hit in QA and by doctors. Without breaking down entire calls. QA for a TCA overdose. Reason is that person gives Narcan for every pill overdose. Told by a doc rather forcefully when I brought unresponsive drunk that pupil response has nothing to do with opiates being onboard. Narcan was promptly pushed in the ER with no response. I guess I should have come out swinging from the beginning. I think it is stupid medicine to have an I ALWAYS do (insert thing here) process. I say the question is legitimate when peers hear you had an unresponsive and they weren't there and ask that.

Keep in mind that every medical director or doctor in the ER is not an ER doctor. A lot of times they will be family med, internal med or surgeons and they all seem to still believe in the coma cocktail. It sounds like you made the right call, especially since it was a TCA overdose.

 

[DrParasite]

An unresponsive drunk with bottle in hand would seem to be a recipe for disaster coupled with Narcan administration.

Can you explain why it is a recipe for disaster? Last I checked, there are no side effects to giving Narcan to a person without opioides in their system.

Allow me to throw this out there, for discussion purposes only: Why would you not? If it's a bleed, than it will have 0 negative effect. If they unconc due to another drug, it will have no effect. if they are having a medical condition, there won't be any downsides.

I am not saying you should slam 2 MG and walk out of the room, but an unconc with no known cause? is there any harm? and if it does correct their issue, and they have an unusual opioid related overdose with unusual S/S, now they can maintain their own airway, can tell you what happened.

I can test BGLs in the field, but I can't run a drug screen on someone. And if they do respond to the narcan use, doesn't that tell you something about the cause of the patient's condition?

 

[Rialaigh]

Can you explain why it is a recipe for disaster? Last I checked, there are no side effects to giving Narcan to a person without opioides in their system.

Allow me to throw this out there, for discussion purposes only: Why would you not? If it's a bleed, than it will have 0 negative effect. If they unconc due to another drug, it will have no effect. if they are having a medical condition, there won't be any downsides.

I am not saying you should slam 2 MG and walk out of the room, but an unconc with no known cause? is there any harm? and if it does correct their issue, and they have an unusual opioid related overdose with unusual S/S, now they can maintain their own airway, can tell you what happened.

I can test BGLs in the field, but I can't run a drug screen on someone. And if they do respond to the narcan use, doesn't that tell you something about the cause of the patient's condition?

I believe the concern there was the heavily intoxicated unresponsive person WITH opiodes in his or her system. I have concerns about waking this person up even a little bit because we have a large patient population that will become semi (barely) responsive and then also begin to vomit, we are unable to get them more awake because of the amount of alcohol in their system and we run the risk of losing an airway very rapidly. If I have a person who is unresponsive, breathing 6 times a minute, with a high suspicion of multi substance abuse (a variety of benzos with alcohol and opiodes) then the patient will probably get a tube or at least some airway management, Not narcan.

I think throwing narcan at suspected stroke patients who are completely unresponsive, or cardiac arrest with any suspicion at all of the possibility of opiode use is very reasonable.

 

[VentMonkey]

Can you explain why it is a recipe for disaster? Last I checked, there are no side effects to giving Narcan to a person without opioides in their system.

Allow me to throw this out there, for discussion purposes only: Why would you not? If it's a bleed, than it will have 0 negative effect. If they unconc due to another drug, it will have no effect. if they are having a medical condition, there won't be any downsides.

I am not saying you should slam 2 MG and walk out of the room, but an unconc with no known cause? is there any harm? and if it does correct their issue, and they have an unusual opioid related overdose with unusual S/S, now they can maintain their own airway, can tell you what happened.

I can test BGLs in the field, but I can't run a drug screen on someone. And if they do respond to the narcan use, doesn't that tell you something about the cause of the patient's condition?

Why don't you simmer down and read the rest of that post? I explained it quite well, as others including the op, responded.

I am not gonna explain or repost it. I will add this to the bleed question though, along the lines of it not having "any side effects".

Last I checked it has been known to induce vomiting in certain patient populations, if said patient has a bleed coupled with any sort of trigger to further increase the likelihood of them vomiting, aspirating, and now developing aspiration pneumonia, why risk it "just because we can, it's safe, or I ruled it out"?

 

[DrParasite]

Last I checked it has been known to induce vomiting in certain patient populations, if said patient has a bleed coupled with any sort of trigger to further increase the likelihood of them vomiting, aspirating, and now developing aspiration pneumonia, why risk it "just because we can, it's safe, or I ruled it out"?

Last I checked (and my info might be out of date), it should only induce vomiting in people with opioids in their system (sort of like a super withdrawl). Was there another population that I was not aware of?

 

[VentMonkey]

Last I checked (and my info might be out of date), it should only induce vomiting in people with opioids in their system (sort of like a super withdrawl). Was there another population that I was not aware of?

I can respect that. I think my point is more along the lines of who's to say who has or hasn't had an opioid-induced bleed (think "speedballs")?

This is where my clinical knowledge will cease, or not in the field, if I suspect this is in fact the case.

Again though, shouldn't good prehospital providers be encouraged to think outside the box, and use sound clinical judgment instead throwing things from a "tool kit" at someone?

If there's something leading me to believe there's no reason to give it, I'm not. Chances are, it can wait until we get to the ED anyhow.

The only time I see fit to deliver Narcan is what I have already stated, as have the majority of others on here (this should tell you something). I use it to reverse their decreased respiratory drive so that they can begin to slowly come out of their narcotic-induced state on their terms.

It all boils down to two words to me: patient advocacy; perhaps you as well, which carries through via a healthy debate.

Still, I would love to hear from @Nova1300, and/ or perhaps @ERDoc can further enlighten the both of us.

 

[Carlos Danger]

Naloxone has one indication, and one indication only: respiratory depression which is suspected to have been caused by opioids.

Narcan should not be used as part of a "coma cocktail", or just because someone is unresponsive and we don't know why. It does have potentially negative side effects. Sympathetic surge (hypertension, tachycardia, pulmonary edema, etc), seizures, nausea, heart block, etc. can all result from naloxone. These are much less common with the smaller doses that are (finally) being used, but they are potential consequences of your choice to give the drug. We've all seen at least one example of someone having an unexpectedly dramatic reaction to something that someone gave them. As uncommon as it may be, bad things can happen when we inject a powerful chemical into someone's bloodstream, especially if it's something they don't need. So that's why we don't give it unless there is a clear reason.

Now that said, given the severity of the opioid crisis that we are experiencing, I don't think there is anything wrong with having a high index of suspicion for opioid overdose in a comatose or very lethargic patient, and a fairly low threshold for using naloxone for that reason.

But you still need to have respiratory depression, and I think you still need to have some reason to think that the cause of the respiratory depression is opioids, in order to justify its use.

 

[rescue1]

I believe the concern there was the heavily intoxicated unresponsive person WITH opiodes in his or her system. I have concerns about waking this person up even a little bit because we have a large patient population that will become semi (barely) responsive and then also begin to vomit, we are unable to get them more awake because of the amount of alcohol in their system and we run the risk of losing an airway very rapidly. If I have a person who is unresponsive, breathing 6 times a minute, with a high suspicion of multi substance abuse (a variety of benzos with alcohol and opiodes) then the patient will probably get a tube or at least some airway management, Not narcan.

I think throwing narcan at suspected stroke patients who are completely unresponsive, or cardiac arrest with any suspicion at all of the possibility of opiode use is very reasonable.

According to the ACLS guidelines for at least a few years now, narcan is not indicated for cardiac arrest. Presumably you are performing CPR on these patients which means that the patient is being ventilated in some capacity, which means trying to restore the breathing before getting ROSC is kind of useless. Besides, if you get pulses back, do you really want to wake up your intubated patient and have him trash around seconds after being pulseless?

For respiratory arrest with a pulse it's a different story, but in true cardiac arrest it has no role.

I agree with everything else you said though.

 

[ERDoc]

It is pt dependent. ACLS are guidelines, not laws. I wouldn't fault someone for pushing narcan in a cardiac arrest if there was a real reason to suspect opiate OD. Let's not go back to the days of "well, it could be so let's push it anyway." Another thing to keep in mind is that there are a huge number of people on chronic opiates. Just because they are unconscious doesn't not mean that those opiates are the cause. So now, you could take someone who is drunk, has a head bleed or other cause of unconsciousness that could be associated with the risk of vomiting/aspiration and you are going to push narcan and put them into withdrawal. So, now you have exacerbated the problem and increased their risk of aspiration. I've shared a story here before where EMS picked up a woman on high dose opiates (that's a whole other story) from a nursing home (where her meds were controlled) and slammed her with 2 2mg doses of narcan. Now I have to deal with the anxious, withdrawing pt with a heart rate in the 150s and BP 210/150 who is puking like there is no tomorrow. Couldn't get her down with gallons of ativan and she ended up needing to be tubed because she was tiring. What is done in the field can have long term consequences for the pt. This lady ended up needing a central line and chest tube during her hospital stay.

 

[Nova1300]

I wonder if doxapram would have any utility in conjunction with naloxone for OD's of these exotic synthetic opioids.

Even much larger-than normal doses of naloxone often don't work, per many reports. What if we sensitized the chemoreceptors with doxapram in addition to using naloxone to reverse as much of the mu2 binding as possible?

What do you think, @Nova1300? I've only read about doxapram; never used it.

This is a tough one Remi. It's not a drug I have used much because the mechanism doesn't make clinical sense to me. And in the critically ill population, metabolic abnormalities are frequently associated with compensatory or co-existing respiratory abnormalities. I think throwing doxapram into the mix there really just muddies the waters. I'm not sure if it would actually have clinical effect or not.

I also appreciate the brief comment above about narcan. It is NOT a benign drug. That sympathetic surge, when it occurs, is very real and can certainly cause clinical deterioration. I can count on one hand the number of times I have given narcan since I finished my residency training. I have, however, placed plenty of endotracheal tubes in patients who got a bit too much opiate. The last time I gave it was in fellowship on a gentleman who was 3 days out from an esophagectomy. With a dose of 0.08 mg he became violently delirious and went into a.fib. He ended up intubated anyway for rapidly developing hypoxia.

Haven't given it since.

Is it probably reasonably safe in young patients, in small doses for pure opiate overdose. However, more and more we are seeing the chronically ill on long-term opiate medications. I do not think narcan is a great idea in this population. I recognize that the prehospital environment is a little different than the ICU, but in an older patient with altered mental status where opiate overdose is not the clear cause, my preference is to establish an airway and allow for diagnostics before administration of reversal agents. But, that is simply my preference.

 

[skro777]

The Narcan tipping point for me personally is when someone is unable to maintain their own airway and resp. drive is affected. I have had a few instances where someone was sleepy from one too many of their pain killers, but was still easily awoke and able to maintain at >94% via NC and just let them take their nap on the ride in. Family calling 911. Most doctors that I have spoke with on this issue agree to with hold if patient can maintain on their own.

 

[rescue1]

The Narcan tipping point for me personally is when someone is unable to maintain their own airway and resp. drive is affected. I have had a few instances where someone was sleepy from one too many of their pain killers, but was still easily awoke and able to maintain at >94% via NC and just let them take their nap on the ride in. Family calling 911. Most doctors that I have spoke with on this issue agree to with hold if patient can maintain on their own.

That's what we used to do at work. Basically we'd say "as long as you can stay awake and breathing, we won't give you Narcan". We were flexible on the awake part, but either way all the patients were very cooperative (for obvious reasons).

We invented this rule after a certain night shift captain slammed narcan on an complient, awake, and breathing but drowsy OD and ended up fighting him all the way to the hospital for no reason.

 

[Rialaigh]

I will say that our service is beginning to move towards a possible treat and release approach with uncomplicated accidental narcotics overdoses. Someone who was getting high or partying. We are in certain cases waking these people up on scene, doing a ALS workup for a refusal, and sticking around for a while and then getting signatures and letting them go sleep the rest of their night away in their bed instead of taking up resources at a hospital and causing a several thousand dollar bill to "be watched" often times in the hallway of an ER with no monitor or pulse ox anyway. I think the uncomplicated overdose patient (especially heroine) is likely someone that does not need an emergency room.

I understand the arguments for the half life of Narcan compared with the half life of the potential drugs that are being abused. The reality is there are very safe ways to bring these people around, reverse the agent they used to overdose, and make a determination on the effective safety of a refusal, and then release them with a signature and witness signatures and the information of the person they are going home with who is going to "care for them". The absurdity of "watching" these people in the hallway of an overcrowded ER for 8 hours and then letting them walk out and sending them a several thousand dollar bill is a real problem. Patient advocate doesn't mean just being a "medical advocate" for the patient, and I believe this concept is lost on many of our current providers. Lets take a look at the research, the problem, and come up with a better solution then hauling a sleeping patient with no current complaint to the ER.

 

[Nova1300]

I will say that our service is beginning to move towards a possible treat and release approach with uncomplicated accidental narcotics overdoses. Someone who was getting high or partying. We are in certain cases waking these people up on scene, doing a ALS workup for a refusal, and sticking around for a while and then getting signatures and letting them go sleep the rest of their night away in their bed instead of taking up resources at a hospital and causing a several thousand dollar bill to "be watched" often times in the hallway of an ER with no monitor or pulse ox anyway. I think the uncomplicated overdose patient (especially heroine) is likely someone that does not need an emergency room.

I understand the arguments for the half life of Narcan compared with the half life of the potential drugs that are being abused. The reality is there are very safe ways to bring these people around, reverse the agent they used to overdose, and make a determination on the effective safety of a refusal, and then release them with a signature and witness signatures and the information of the person they are going home with who is going to "care for them". The absurdity of "watching" these people in the hallway of an overcrowded ER for 8 hours and then letting them walk out and sending them a several thousand dollar bill is a real problem. Patient advocate doesn't mean just being a "medical advocate" for the patient, and I believe this concept is lost on many of our current providers. Lets take a look at the research, the problem, and come up with a better solution then hauling a sleeping patient with no current complaint to the ER.

Does this include patients with other co-existing disease states? I would absolutely NOT obtain a refusal on a patient with renal failure who required naloxone. Nor one with coronary artery disease. Nor seizure disorder.

I think your service has bigger balls than I

 

[Carlos Danger]

I will say that our service is beginning to move towards a possible treat and release approach with uncomplicated accidental narcotics overdoses. Someone who was getting high or partying. We are in certain cases waking these people up on scene, doing a ALS workup for a refusal, and sticking around for a while and then getting signatures and letting them go sleep the rest of their night away in their bed instead of taking up resources at a hospital and causing a several thousand dollar bill to "be watched" often times in the hallway of an ER with no monitor or pulse ox anyway. I think the uncomplicated overdose patient (especially heroine) is likely someone that does not need an emergency room.

I understand the arguments for the half life of Narcan compared with the half life of the potential drugs that are being abused. The reality is there are very safe ways to bring these people around, reverse the agent they used to overdose, and make a determination on the effective safety of a refusal, and then release them with a signature and witness signatures and the information of the person they are going home with who is going to "care for them". The absurdity of "watching" these people in the hallway of an overcrowded ER for 8 hours and then letting them walk out and sending them a several thousand dollar bill is a real problem. Patient advocate doesn't mean just being a "medical advocate" for the patient, and I believe this concept is lost on many of our current providers. Lets take a look at the research, the problem, and come up with a better solution then hauling a sleeping patient with no current complaint to the ER.

I completely agree with the second part of your post that I bolded. It is time for EMS to start doing more / different things than just loading people into the ambulance and taking them to the hospital. Very often that isn't the best thing for the patient or for the system.

The problem is that I just can't help but wonder about the first part that I bolded. Is it really safe to wake people up with narcan and then leave them? I'd bet that the large majority of the time you'd have no problems at all. But it seems like a risky thing to do, considering the possibility of re-narcotization. I suppose if you had good reason to believe that the person watching them was responsible and trustworthy, that makes all the difference.

I'm not against the idea - I think it is interesting. I just can't help but wonder about the safety of it.

And I've never heard of anyone else doing this. Once you guys have been doing it for a while, you should definitely try to publish in PEC.

 

[Rialaigh]

I completely agree with the second part of your post that I bolded. It is time for EMS to start doing more / different things than just loading people into the ambulance and taking them to the hospital. Very often that isn't the best thing for the patient or for the system.

The problem is that I just can't help but wonder about the first part that I bolded. Is it really safe to wake people up with narcan and then leave them? I'd bet that the large majority of the time you'd have no problems at all. But it seems like a risky thing to do, considering the possibility of re-narcotization. I suppose if you had good reason to believe that the person watching them was responsible and trustworthy, that makes all the difference.

I'm not against the idea - I think it is interesting. I just can't help but wonder about the safety of it.

And I've never heard of anyone else doing this. Once you guys have been doing it for a while, you should definitely try to publish in PEC.

I believe our service is moving forward towards some very exciting progressive protocols.

Our current protocol came about from first responders utilizing narcan prior to EMS arrival on suspected overdoses. This has become common practice in several states around here that have law enforcement and fire department carrying narcan. We get on scene and the patient is now alert and oriented and obviously does not want to go to the hospital the majority of the time. We stay on scene with the patient for 30 minutes, do standard refusal paperwork, vitals. We monitor for signs of increased lethargy or respiratory depression or onset of altered status or diminished LOC during the 30 minutes. Currently we can write the refusal and get signatures, and we have the option to contact our med control for a 2mg narcan booster at the end of the two minutes if the patient is competent to refuse however we have concerns about them going back into diminished LOC and respiratory depression from the narcotics at a later point. We are just starting to trial this and I imagine the protocol will expand and begin to be utilized more often. We have the support of the hospitals who don't want half a dozen of these patients every night taking up 6 hallway beds only to be discharged 8 hours into the night when they wake up and get a ride.

Generally speaking we aren't waking these people up (as far as EMS giving the narcan) without someone on scene who can give us a good idea that its a simple narcotics overdose without suicidal intentions. Usually those same people are the ones that say the patient was just taking some pills and having a good night and they will be with them the rest of the night and make sure they are okay. We make sure to get full information of the party that insists they will take care of them and call back if needed.

Anyways, in the region I am in my system probably responds to a dozen overdoses a day, probably 1 or 2 getting narcan. We have very few ill effects with narcan and it is usually just some nausea.


If anyone else is currently doing any form of "treat and release" program with narcotics overdoses I would love to get your view on it