The Combative Opiate Patient

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Elk Oil

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I've done some searching and can't find any discussion on this, so I thought I'd throw it out there and get some of your experiences.

We all know that generally-accepted practices surrounding the use of narcan for opiate overdoses. We've heard the prevailing philosophy that the patient (may/will) awaken and become violent. In fact, I've worked with some EMTs who refused to administer it in the field because of their fear of what the newly-conscious patient would be like.

My question is this:
How much are these fears rooted in reality and how much in lore?

I've seen loads of heroin overdoses treated with narcan over the years and have never experienced a violent patient. All my patients have been confused and lethargic. Some even apologetic.

Thanks for sharing your thoughts and experiences.
 
Use protocols not "generally accepted practices".

I have not seen someone come up swinging from Narcan, but my experience with that is limited. I've seen diabetics come up swinging after glucose a couple times.
 
Ive had several come up swinging. However, they are usually not solely opiate ODs (of course, we don't know this at the time...). All the ones I've had come up swinging are typically speedballing. Meth or coke. Brown is a popular one around here too (No, not you, Brown :p )
 
I try not to slam Narcan. I push it slowly to return normal respiration / maybe wake them slowly. Groggy patient = a losing patient in a fight.



I've had more trouble with postictal patients....
 
Linuss said:
I've had more trouble with postictal patients....
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This. And I think I pushed Narcan my first time 3 days after starting working as a basic. I usually will only give enough to bring their respirations back to normalish. I don't bother trying to wake up the OD most times
 
Maybe my experience is atypical, but I can count on one hand the number of times I've had a patient truly depressed enough for naloxene. And I could have gotten by with suction an NPA and a BVM.

I typically don't push the stuff in the field. Not because I'm scared of a violent awakening, just because there's no need.
 
usalsfyre said:
Maybe my experience is atypical, but I can count on one hand the number of times I've had a patient truly depressed enough for naloxene. And I could have gotten by with suction an NPA and a BVM.

I typically don't push the stuff in the field. Not because I'm scared of a violent awakening, just because there's no need.
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If our city transported every pt that was found as an unconscious opiate OD, our hospitals would be over-crowded and on diversion all day long. We actually on a very regular basis will administer Narcan, wake them up, and give an IM maintenance dose before obtaining a refusal (assuming no other issues present themselves). Say what you will about it being right or wrong. One of our Level 1/Universities recently completed a study on no-transport opiate ODs with Narcan administration. No patients seen and treated by EMS were seen by the hospital or ME/Coroner within 48hrs of treatment over a 2 or 3 year period. Now our hospitals and medical director encourage this practice.
 
PoeticInjustice said:
If our city transported every pt that was found as an unconscious opiate OD, our hospitals would be over-crowded and on diversion all day long. We actually on a very regular basis will administer Narcan, wake them up, and give an IM maintenance dose before obtaining a refusal (assuming no other issues present themselves). Say what you will about it being right or wrong. One of our Level 1/Universities recently completed a study on no-transport opiate ODs with Narcan administration. No patients seen and treated by EMS were seen by the hospital or ME/Coroner within 48hrs of treatment over a 2 or 3 year period. Now our hospitals and medical director encourage this practice.
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But...we've established in the past the situation in your city is atypical as well.
 
PoeticInjustice said:
If our city transported every pt that was found as an unconscious opiate OD, our hospitals would be over-crowded and on diversion all day long. We actually on a very regular basis will administer Narcan, wake them up, and give an IM maintenance dose before obtaining a refusal (assuming no other issues present themselves). Say what you will about it being right or wrong. One of our Level 1/Universities recently completed a study on no-transport opiate ODs with Narcan administration. No patients seen and treated by EMS were seen by the hospital or ME/Coroner within 48hrs of treatment over a 2 or 3 year period. Now our hospitals and medical director encourage this practice.
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That sounds like a system I wanna work in :p
 
I can't remember ever fighting a post-narcotic OD patient. The lore on this one drives. me. batty.

Just the other day, I had a patient who OD'd on who knows what and had drunk a case of beer. She was totally unconscious, with a heart rate of 160, hypotensive, and breathing mostly adequately, although not protecting her own airway. Her pupils were sluggish at 2 mm.

I gave her 2 mg of narcan, not because I was suspecting narcotic OD (people just don't get into that much in our rural county...much more likely to be other stuff). Anyway, I gave the narcan because I knew I'd catch heck for it in the er if I didn't give it to her.

Later, when she'd woken up some (well after the narcan dose, not related), she was fighting, and nearly hurting herself, so I ended up giving some versed to put her back into lala land.

Ends up, I caught heck in the ER because of my "ridiculous" dose of narcan which "OBVIOUSLY" was the reason she was combative.

Seriously, I've given narcan in 2 mg increments to actual narcotic ODs and the only adverse reaction has been shivering and puking. Not so much on the fighting. We'll save that for the post-ictal pts and the post-hypoglycemic pts.
 
PoeticInjustice said:
Fair enough :p



Not if you currently enjoy EMS! That's why I got my part-time job! Lol! We will hopefully be getting some big changes soon, though :D
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Big changes????? I'm interested to see what y'all are doing.


Sent from my electronic overbearing life controller
 
TransportJockey said:
This. And I think I pushed Narcan my first time 3 days after starting working as a basic. I usually will only give enough to bring their respirations back to normalish. I don't bother trying to wake up the OD most times
Click to expand...

Same thing I do. Keep the breathing decent and let em sleep.


Sent from my electronic overbearing life controller
 
Elk Oil said:
I've done some searching and can't find any discussion on this, so I thought I'd throw it out there and get some of your experiences.

We all know that generally-accepted practices surrounding the use of narcan for opiate overdoses. We've heard the prevailing philosophy that the patient (may/will) awaken and become violent. In fact, I've worked with some EMTs who refused to administer it in the field because of their fear of what the newly-conscious patient would be like.

My question is this:
How much are these fears rooted in reality and how much in lore?

I've seen loads of heroin overdoses treated with narcan over the years and have never experienced a violent patient. All my patients have been confused and lethargic. Some even apologetic.

Thanks for sharing your thoughts and experiences.
Click to expand...

My (limited) experience when working ALS, and seeing others use it IN BLS has been that the risk of violence is proportional to the rate you push it... if IV slamming or even brisk administration = agitation and vomiting. Slow and steady (over 2 min or so), and a smaller initial dose = calm, breathing patient.
 
shfd739 said:
Big changes????? I'm interested to see what y'all are doing.


Sent from my electronic overbearing life controller
Click to expand...

It'll come in three stages. Stage 1 has about 25 new medications, some being:
Adenosine
Benadryl
Fentanyl
Versed
Dopamine
Levophed
Nitro drips
And many more, plus:
IV pumps
Video laryngoscopy (Ha!)
Bougies
NG tubes

Later phases aren't set in stone yet but will contain Etomidate, Ketamine, RSI, and ultrasound.

Don't laugh at us! :p We had a fairly archaic and very limiting medical director prior to our current one, so we're trying to catch up and jump ahead all at once (with appropriate steps for training of course)
 
We have been administering narcan to overdoses for decades, treat and release and very, very seldom have had any issues.
There are two key points: oxygenate well prior to administering narcan. A hypoxic head will give you an angry patient, so get them well oxygenated and well ventilated first.
Then, give it gently. We don't even give it IV, IM is much nicer, it wakes them up slowly and smoothly, no angry, no sweating, no shaking, no vomiting. They wake up, shake our hands and go home.
As a service we have been following this approach for about a decade or so, and have never had any issues. We also, as a service, used to see quite literally hundreds of heroin overdoses a day.
 
PoeticInjustice said:
It'll come in three stages. Stage 1 has about 25 new medications, some being:
Adenosine
Benadryl
Fentanyl
Versed
Dopamine
Levophed
Nitro drips
And many more, plus:
IV pumps
Video laryngoscopy (Ha!)
Bougies
NG tubes

Later phases aren't set in stone yet but will contain Etomidate, Ketamine, RSI, and ultrasound.

Don't laugh at us! :p We had a fairly archaic and very limiting medical director prior to our current one, so we're trying to catch up and jump ahead all at once (with appropriate steps for training of course)
Click to expand...

I would have thought some of thse were already pretty standard issue, adenosine and benadryl in particular.
 
All the medics I have worked with so far will only push enough to keep them stable but still not conscious. Then once we pull up to the hospital they will push a little more so the patient wakes up and can answer the hospitals questions. Better to have an aggressive patient at a hospital with countless people there then to have an aggressive patient in the back of the rig when it's just you and the patient.
 
jwk said:
I would have thought some of thse were already pretty standard issue, adenosine and benadryl in particular.
Click to expand...

Preaching to the choir, buddy
 
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