usafmedic45
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Eh....not a huge deal. I used to give it via a sublingual injection in patients without IV access.
The Combative Opiate Patient
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Eh....not a huge deal. I used to give it via a sublingual injection in patients without IV access.
When you come across a patient like this there's nothing wrong with exposing them, not only for the sake of finding an IV but you have no idea why they're down. You need to be able to assess their entire body. Obviously depending on the kind of clothing there are different ways you can do it, you want to maintain some decency and respect for them (obviously have blankets handy to promptly cover them up) but you need to see if there's a trauma or other reason this person is down. It always looks great when you take someone to the hospital and report no injuries and then the hospital staff exposes the patient and finds something you missed because you didn't expose them and get a proper assessment. I've seen it happen and it's not good.
As for the use of an IO, it's common practice and in most people's protocols. You obviously attempt regular IV access first, and some would opt for an EJ before an IO but there's nothing "wrong" with using one if it's that or no IV access at all. It's in the protocols for a reason.
dixie_flatline
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I didn't quite read every post, but thought I'd throw out my (admittedly Basic) experiences. I've been on 2 or 3 calls in the past few months where we pushed narcan (we use IN narcan - does anyone else?). I think that a lot of the "come up swinging" stories might stem from providers instigating.
This is just a theory, but the really depressed opiate ODs I've been on, the narcan does bring them up in a few minutes, but they're usually disoriented, confused, and their body is obviously feeling a bit of a system shock. A lot of providers seem to talk down to, or ignore, the pt who almost always has a lot of questions, is worried about the cops, etc. Having some (ahem) patience with the patients seems to curb the so-called violent tendencies.
This is just a theory, but the really depressed opiate ODs I've been on, the narcan does bring them up in a few minutes, but they're usually disoriented, confused, and their body is obviously feeling a bit of a system shock. A lot of providers seem to talk down to, or ignore, the pt who almost always has a lot of questions, is worried about the cops, etc. Having some (ahem) patience with the patients seems to curb the so-called violent tendencies.
8jimi8
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I'm not trashing you, Bro, but that didn't work in the nuremberg trials. Following orders is no reason to follow illegal orders.
***not to say that exposing the patient isn't proper.
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usafmedic45
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Yeah it's in our protocols to do so.
Frusemide: Hey bro, what are you doing here?
Naloxone: I'm not wanted either bro!
Lidocaine: Aw man, not another one!
Bretylium: Yeah man its getting crowded in here!
Procainamide: Everyone forgets about me!
Verapamil: At least you don't have "kill" in your nickname...
Chief Complaint
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I know you arent, i didnt mean to sound so defensive.
If they had asked me to do something that wasnt in my scope or that i didnt feel was appropriate, i wouldnt have done it. I didnt feel that exposing the patient would be detrimental so i went ahead and did it.
usafmedic45
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Isoproterenol: 'Bout damn time you guys got here.
8jimi8
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i didn't see you being defensive. i also posted this in between sleep sessions this morning. so i don't even see what illegal orders we were talking about anymore haha.
this is a large hint not to sleep with my phone laying next to me in the bed.
Ok hears what I've learned over the years working in a few different places (private, paid on call ALS, big city). Most common thing that leads to fighting is giving Narcan to an A&Ox4 pt who is high on a narcotic. They are fully aware that you are taking away there "high".
Second, "slamming" Narcan leads to immediate puking and probably 50% chance fighting.
Here is my rule and what I'm starting to see as our new state protocol. Narcan is given for altered mental status, and DECREASED RESPIRATIONS. You may or may not have other findings. But if you do not have these two there is no need for Narcan. All you need is 0.4mg in almost every situation. Start there give it 2 minutes or so while assisting respirations with BVM. If that does not work give another 0.4mg until you improve respiration then stop. No need to totally wake the pt while in there house, ally, or whatever. I guarantee if you give enough to improve respirations the pt will be alert on arrival to hospital.
Sometimes fighting is inevitable. If you feel like this is going to be the one. Restrain the pt prior to Narcan if protocol allows.
P.S. Stop saying Narcan is for opiate OD. Narcan is for narcotic overdoses. A narcotic is anything derived from Opium, synthetic (opioid) or natural (opiate). Please look it up if you don't believe me.
If you have any resource to prove this wrong please let me know because I would feel like a real dumb butt if I was wrong about this
Second, "slamming" Narcan leads to immediate puking and probably 50% chance fighting.
Here is my rule and what I'm starting to see as our new state protocol. Narcan is given for altered mental status, and DECREASED RESPIRATIONS. You may or may not have other findings. But if you do not have these two there is no need for Narcan. All you need is 0.4mg in almost every situation. Start there give it 2 minutes or so while assisting respirations with BVM. If that does not work give another 0.4mg until you improve respiration then stop. No need to totally wake the pt while in there house, ally, or whatever. I guarantee if you give enough to improve respirations the pt will be alert on arrival to hospital.
Sometimes fighting is inevitable. If you feel like this is going to be the one. Restrain the pt prior to Narcan if protocol allows.
P.S. Stop saying Narcan is for opiate OD. Narcan is for narcotic overdoses. A narcotic is anything derived from Opium, synthetic (opioid) or natural (opiate). Please look it up if you don't believe me.
If you have any resource to prove this wrong please let me know because I would feel like a real dumb butt if I was wrong about this
Aidey
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Narcotic is an ambigious term and it isn't really used in proper pharmacology. It used to mean any mind altering substance, not just opioid based compounds.
Also, all opiates are opioids, but not all opioids are opiates, so really we should be using opioid in this discussion. However, few people bother to differentiate between the two in casual conversation, and I doubt people are going to start now.
Also, all opiates are opioids, but not all opioids are opiates, so really we should be using opioid in this discussion. However, few people bother to differentiate between the two in casual conversation, and I doubt people are going to start now.
lightsandsirens5
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...and time to lock the thread.
I know!
Unfortunately it is a very productive and informative thread so far, so we'll just let Godwin sleep through this one.
the_negro_puppy
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Why are people pushing for immediate IV access for a suspected opioid overdose? why not push IM/IN narcan first while managing airway/ventilation and see the pt's response before cutting up clothes and starting lines.
We are instructed that IV access should not normally be attempted done with opioid overdoses unless there are other complications and naloxone doesnt work.
We are instructed that IV access should not normally be attempted done with opioid overdoses unless there are other complications and naloxone doesnt work.
Smash
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What is was her actual problem when you arrived? Would hypoxia secondary to respiratory depression sound reasonable?
If so, why not ventilate and oxygenate her. Problem solved. Then you can attach ECG leads to wrists and ankles (they are limb leads you know) and either administer some IN or IM naloxone. Or you could roll her sleeves up to find an IV site if you absolutely must give IV naloxone.
I accept that you were an intern then; what would you do in the same situation now?
usafmedic45
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Yup. That's pretty much my approach.
Smash
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I have a nasty suspicion that it is punitive, especially when people are talking about starting an IO for what seems just to be :censored::censored::censored::censored:s and giggles.
Melclin
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I must typed a pile of responses last night and just not sent them.
IO narcan? How absurd.
IM first choice. I have heard that when they've been down long enough, esp in a cold environment you have to give it a while and maybe top it up but it certainly works well. My experience is limited with it but the first time I gave it, the bloke came a shook my hand and thanked me afterwards. I've never seen anyone get pissed off, just look a little crook.
I've been interested in IN route for a while because I like the idea of not having to wield a needle around that I've just stuck in a hep c pt. But if I remember correctly, there were some issues with the concentration of the preparations currently available in that its a little too dilute for IN. Still works, just not as well.
Wouldn't the IN route be a little faster and therefore less desirable?
IO narcan? How absurd.
IM first choice. I have heard that when they've been down long enough, esp in a cold environment you have to give it a while and maybe top it up but it certainly works well. My experience is limited with it but the first time I gave it, the bloke came a shook my hand and thanked me afterwards. I've never seen anyone get pissed off, just look a little crook.
I've been interested in IN route for a while because I like the idea of not having to wield a needle around that I've just stuck in a hep c pt. But if I remember correctly, there were some issues with the concentration of the preparations currently available in that its a little too dilute for IN. Still works, just not as well.
Wouldn't the IN route be a little faster and therefore less desirable?