Should we use Narcan on all CPR calls?

[VentMonkey]

no, I read it from start to finish..... I see your point, but your point doesn't negate my question....

I think you're missing the point entirely. Why don't you do review the studies on how beneficial public access narcan is?

And more importantly, why don't you answer my questions?

BTW, I agree we should give medications only if they are indicated. But if it can help the patient (even if not in the immediate situation, but in the near future), why not?

Why? We'd be arguing similar points of views.

That's where conservative narcan pushes comes into play.

No need to have a combative peri-arrested opiate OD flailing about.

 

[EpiEMS]

because once we get the heart started again, the body will still need to deal with the effects of the OD, which very likely caused the cardiac arrest. if you don't treat the OD, it's very likely to reoccur. and if we have extra hands to do some IN naloxone, while doing CPR and defib, is that really a bad thing?

It certainly won't help the secondary issue. Like you said high quality cpr and early defibrillation are proven for a full arrest. However, if you gain ROSC and your patient starts to breathe on their own you'll want something to block the receptors that opiants bind to. That's where narcan comes into play.

@DrParasite and @CALEMT, I've got no concern with throwing on some IN naloxone if we've got the extra hands, that's totally fair. That said, if I've got a BVM, I can correct hypoxia - I don't need naloxone. Heck, it's operationally easier to deal with an apneic post arrest patient than a combative one, as @VentMonkey says.

 

[GMCmedic]

This wont be a favorable opinion but I typically prefer intubation over Narcan in most cases.

I have never administered Narcan during a code and I dont see myself ever routinely doing so.

I have no issues with OTC narcan or Police carrying Narcan. We will not replace it for PD so if they want to administer it to every unconscious person they encounter then go for it, doesnt affect our budget.

However, i still believe PD can serve a greater percentage of the population if officers had oxygen and BVMs. Thats not mainstream enough though.

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[EpiEMS]

This wont be a favorable opinion but I typically prefer intubation over Narcan in most cases.

Any particular reason why?

However, i still believe PD can serve a greater percentage of the population if officers had oxygen and BVMs. Thats not mainstream enough though.

I certainly hope most do - in my response area, they are all EMRs (at minimum), and have AED, BVM, O2, and a trauma kit (oh, and naloxone).

 

[GMCmedic]

Any particular reason why?



I certainly hope most do - in my response area, they are all EMRs (at minimum), and have AED, BVM, O2, and a trauma kit (oh, and naloxone).

Our Sherriffs office and town PD's are stretched thin. Its near impossible to get them to cuff anyone or ride along if needed.

I was once told by an officer that if a patient gets violent I can just get in my bag of tricks and put them back down. I Dont see much point in waking them up from the start if thats what Im going to have to do.

We currently have one department getting AEDs no other medical plans are in the works that ive heard of. Two departments have Narcan, the other two dont want it. At least they all have tourniquets.

And when I say stretched thin, we might have 8 cops total between 4 departments covering 400 square miles and 4 of those will be limited to their town limits.

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[E tank]

This thread has taken a kind of surreal turn. I'm not always a fan of reality, so I'll wade in too...without respect to any of the above posts:

1. If I had a full arrest that came about from known narcotic induced apnea, I'd feel comfortable defending giving narcan or not giving it, or delaying giving it, depending on the patients initial response to therapy.

2. Mask ventilation carries it's own risks, such as, not being able to, gastric distention and acute lung injury 2/2 aspiration. Only the operator with mad mask ventilation and keen clinical assessment skills should ever, if at all, consider mask ventilation over narcan in a patient like this, imho. If a wild wake up is to be avoided, why not have someone mask ventilate and someone else feather in a few mcgs of narcan until spontaneous respiration returns?

Again. Stopped reading. Guilty. Just my $ 0.02

 

[Eden]

I certainly dont think we should give narcan to every resus. And i also dont think cops/fire should. I'd rather have them focused on good chest compressions and aed use.
I would give narcan if i suspect opiate od etiology.
And about the raging narcaned patient
Our protocols state narcan is to be given until adequate respirations return.
So usually thats what we do, until we arrive in the ER then we push 2mg and throw them in.
Jking ofc lol

 

[NomadicMedic]

Just as an aside, how many people are regularly slamming huge amounts of Narcan and having their patients wake up flailing and fighting? Do people still really do this?

I've used a lot of Narcan. I worked in Yakima Washington. I used a LOT of Narcan. And in my anecdotal experience, n=1, I have never, ever had an opiate overdose wake flailing and fighting. Normally, after a half milligram of Narcan, they're breathing and if they're starting to wake up, awfully apologetic and embarrassed.

Perhaps a bit more careful titration is in order?

 

[VentMonkey]

Just as an aside, how many people are regularly slamming huge amounts of Narcan and having their patients wake up flailing and fighting? Do people still really do this?

I've used a lot of Narcan. I worked in Yakima Washington. I used a LOT of Narcan. And in my anecdotal experience, n=1, I have never, ever had an opiate overdose wake flailing and fighting. Normally, after a half milligram of Narcan, they're breathing and if they're starting to wake up, awfully apologetic and embarrassed.

Perhaps a bit more careful titration is in order?

I'm not entirely sure, but figured it's something worth occasionally mentioning with the wide array of provider levels on the forum.

 

[E tank]

Well, there's a reason it comes in 0.4 mg vials now as well. It used to only come in 2 mg syringes. Folks learned the hard way. Hypertension, diaphoresis, agitation. Just figured that was what happened when narcotics got reversed. The idea of titration came a little later.

 

[VentMonkey]

Well, there's a reason it comes in 0.4 mg vials now as well. It used to only come in 2 mg syringes. Folks learned the hard way. Hypertension, diaphoresis, agitation. Just figured that was what happened when narcotics got reversed. The idea of titration came a little later.

We---and I believe most services---carry 2 mg preloads nowadays, though our protocols call for incremental doses as I've highlighted in your post because of the vials carried on our ambulances in the past.

As far as learning the hard way, I think it's a fairly common mistake seen with green providers (I did it once or twice), and I think it also goes to show that it in fact is not exactly "harmless" either.

Does it beat having an apneic, and cynaotic patient? Absolutely, but following the directions on the box (or in your protocols) is definitely worth reiterating regardless of training received.

Antidote or not, too much of anything in the wrong hands can cause ill effects ranging from mild, and preventable, to lethal. It's still not the first thing on my mind in an arrest, even of the opiate variety.

 

[ArizonaEMT]

I think its funny to see everyone trying to say Narcan has side effects........ can someone tell me the side effect of death?

With as many opiate overdoses we see out here, I am surprised we do not see a lot more cardiac arrest protocols saying to give Narcan during the first round of resuscitation.

 

[DesertMedic66]

I think its funny to see everyone trying to say Narcan has side effects........ can someone tell me the side effect of death?

With as many opiate overdoses we see out here, I am surprised we do not see a lot more cardiac arrest protocols saying to give Narcan during the first round of resuscitation.

When a patient ODs from a narcotic what is the reason they go into full arrest? What are we already doing that fixes that issue?

If Narcan has zero side effect why do we not give it for neonates who come out with narcotics in their system? What happens if we give a bone cancer patient who is on high dose pain meds Narcan?

 

[CALEMT]

I think its funny to see everyone trying to say Narcan has side effects........ can someone tell me the side effect of death?

With as many opiate overdoses we see out here, I am surprised we do not see a lot more cardiac arrest protocols saying to give Narcan during the first round of resuscitation.

If you have read most of the posts on here narcan in the full arrest setting isn't going to do much, if anything. The heart isn't working properly, the opiate overdose is the least of my worries at this point. The heart is either in pulseless v tach, v fib, asystole, or PEA. All of which narcan isn't going to fix. High quality CPR and early defibrillation for pulseless v tach and v fib are whats going to save the patient. Narcan is just going to block the opiate receptors in the brain. If you gain ROSC then yeah it'll help with reducing the amount of opiates binding with the brain cells. However, you're still going to be ventilating the patient.

Edit: and like every drug and medication on the market, narcan has side effects...

 

[StCEMT]

If you have read most of the posts on here narcan in the full arrest setting isn't going to do much, if anything.

I don't disagree with you, just throwing an extra little bit for thought. I believe it was @Remi (correct me if I am wrong when you see this) that said a while back in another discussion that in high enough doses, heroin/opiates could be a sympatholytic. I personally have never come across an OD that I couldn't handle with .5 or 1mg of Narcan, but that doesn't mean much.

 

[ArizonaEMT]

Desert Medic ...... Not quite sure what you mean by "neonates who come out with narcotics in their system? What happens if we give a bone cancer patient who is on high dose pain meds Narcan?"

Neonates are totally different, and are supported by their mother, after birth they will go into withdraw and are given opiates to combat the effects of Neonatal Abstinence Symdrome. I don't think I have heard about a case where a mother gave birth and the neonate could not breath on its own because of the opiates that were given during utero.

In addition why would it matter if you gave a bone cancer patient narcan who was a code? Is pain not better then death? What if the cancer patient accidentally took to many opiates or intentional overdose which you are not aware of?

 

[DesertMedic66]

Desert Medic ...... Not quite sure what you mean by "neonates who come out with narcotics in their system? What happens if we give a bone cancer patient who is on high dose pain meds Narcan?"

Neonates are totally different, and are supported by their mother, after birth they will go into withdraw and are given opiates to combat the effects of Neonatal Abstinence Symdrome. I don't think I have heard about a case where a mother gave birth and the neonate could not breath on its own because of the opiates that were given during utero.

In addition why would it matter if you gave a bone cancer patient narcan who was a code? Is pain not better then death? What if the cancer patient accidentally took to many opiates or intentional overdose which you are not aware of?

In those patients I was referring that Narcan does have size effects since it seems like you were trying to imply there are no side effects to Narcan.

In the case of bone cancer actually death may sometimes be the better choice for them. And hey if they have a DNR and coded (doesn't matter what caused it) the odds are I am not going to be working them up.

 

[CALEMT]

What happens if we give a bone cancer patient who is on high dose pain meds Narcan?"

In addition why would it matter if you gave a bone cancer patient narcan who was a code?

Maybe you should read up on a medication before you try to make a logical argument about it.

 

[ArizonaEMT]

My point is opiate overdoses go into cardiac arrest primarily because of prolonged respiratory arrest. As part of the resuscitation attempt why would it not be appropriate to push narcan in addition to ACLS drugs. If the patient is an overdose and narcan is not started the patient is not going to be able to breath on their own, we all know or should know about patient outcomes in intubated patients.

Out here our protocols state we do not attempt an advanced airway until 4 rounds of 200 compression with Epi given 1 mg IV/IO are given every 200 compressions.

 

[CALEMT]

As part of the resuscitation attempt why would it not be appropriate to push narcan in addition to ACLS drugs.

Because narcan isn't going to solve the problem of the heart not beating. It's a unnecessary drug to give. Where in the ALCS algorithm does it state to give narcan? Were in your H's and T's does it state to tread a OD?