Versed after Narcan for OD patients?

[Phillyrube]

unrelated, but in the ED, if you have an unconscious opiod user who is breathing, what is done? do they need a 1:1 monitor? do they simply sleep it off like the people who enjoy too much alcohol? or do the EDs give narcan?

I've seen both. Monitor, labs, clear C-spine (unconscious). Usually a CT scan. If the numbers are good, they go on the monitor, monitored at the front desk, and let them sleep. Sucks.

 

[Peak]

unrelated, but in the ED, if you have an unconscious opiod user who is breathing, what is done? do they need a 1:1 monitor? do they simply sleep it off like the people who enjoy too much alcohol? or do the EDs give narcan?

It depends on the patient presentation and the region. If the patient can maintain their own airway but are hypercapnic/hypoxic despite O2 by NC we will given them just enough narcan (typically a small bolus and a titrated drip) to improve their ventilation and give some supplemental oxygen via NC. The patients will be on continuous monitoring by 3 lead, pulse ox, and capnography and are ESI 2 but are not typically 1:1 patients, often they are admitted to the unit but we may watch them in the ED if the unit is near capacity. If patient cannot maintain their own airway despite a reasonable amount of narcan then they will be intubated and will later be extubated in the unit, these are ESI 1 and will be 1:1 until they are tubed then 1:2 shortly after. We are pretty aggressive in prophylactic treatment of nausea/vomiting to prevent aspiration. Typically these patients are discharged within 1-2 days of presentation to the ED. If they are just mildly sedated but are maintaining a good airway and ventilatory status we typically put them on a monitor and put them in a hall bed in front of the nurses station (same as the drunks). We see relatively few opioid overdoses compared to other large metropolitan areas.

From what I've heard it isn't uncommon in the midwest or east coast to give massive narcan doses (I've heard that 10+ mg isn't uncommon) until the patient wakes up and then they... don't stop the patient from leaving very shortly after that. They also have relatively fewer ED beds for the population and it seems that the opioid additics take much larger doses.

 

[ParamagicFF]

unrelated, but in the ED, if you have an unconscious opiod user who is breathing, what is done? do they need a 1:1 monitor? do they simply sleep it off like the people who enjoy too much alcohol? or do the EDs give narcan?

I transport to 6+ hospitals. Every one of them rolls their eyes if a heroin overdose ends up transported to their facility. They will immediately give narcan aggressively until the patient signs out AMA. They will generally draw labs on them as well in case there is more to the case, but little effort is made to keep them from AMAing. Another strategy they use is to not accept the patient into a bad for a while. They will have us wait in the hallway with the hopes that the patient will sober up and leave. This basically applies to any substance we transport.

Regarding the large doses of narcan, anecdotally I can say providers simply don't give it time to work. I've had 6 minute response times where the BLS crew that got there first says "We've already given 6mg with no change". And I've seen physicians order the same. The nurse barely has time to dispose of the IM injection needle before the MD is ordering more narcan.

I think it's very much due to the system not having enough beds to support the amount of drug overdoses we take in a day. Between PCP, K2, and heroin, we can keep most of our beds full most of the day.

 

[Bullets]

Our area cops have recently started carrying 4mg IN Narcan doses and let me tell you, its freakin wonderful pulling up to calls now where either the cops and the patient a rolling, the patient is violently vomiting and shivering, or just flat out seizing. At least with the 2mg the patients were usually awake but a little groggy.

Weve been giving 500mg IM Ketmine for the guys who are fighting, usually 4mg for the seizures and O2 and everyone gets zofran

 

[ParamagicFF]

Our area cops have recently started carrying 4mg IN Narcan doses and let me tell you, its freakin wonderful pulling up to calls now where either the cops and the patient a rolling, the patient is violently vomiting and shivering, or just flat out seizing. At least with the 2mg the patients were usually awake but a little groggy.

Weve been giving 500mg IM Ketmine for the guys who are fighting, usually 4mg for the seizures and O2 and everyone gets zofran

How often is behavior like this happening? I've read a few anecdotes like this on the forum, but never seen any similar behavior aside from the pt defecating, vomiting, or shivering. I've never seen violent behavior. And I run a LOT of heroin calls.

What adds more to my surprise is the fact that in my area, the patients would get away with acting violent towards police and EMS after getting narcan, so there's no reason for them not to. They usually wake up and say "Im good" over and over as they try to disengage and leave the scene.

 

[Bullets]

How often is behavior like this happening? I've read a few anecdotes like this on the forum, but never seen any similar behavior aside from the pt defecating, vomiting, or shivering. I've never seen violent behavior. And I run a LOT of heroin calls.

What adds more to my surprise is the fact that in my area, the patients would get away with acting violent towards police and EMS after getting narcan, so there's no reason for them not to. They usually wake up and say "Im good" over and over as they try to disengage and leave the scene.

Obviously my experience is anecdotal. Most departments have had this 4mg spray for about 2 months now. In that time we have had 6 patients who have needed sedation due to combative behavior post administration. I had yet to sedate anyone this calendar year. I know correlation doesnt equal causation and there may be some other chemicals laced in with this batch but in the ten years ive been doing EMS i never had a combative resus before July 1. Ive always said the same thing your saying, addicts dont fight, they just want to pull the sheet over their head and curl up on the cot.