Versed after Narcan for OD patients?

[Carlos Danger]

Sure, midazolam or ketamine can be used to calm a delirious or angry patient. But there's something about having to sedate a patient whose sedation you just intentionally reversed that should seem wrong on it's face. If your patients are routinely waking up unmanageable after getting naloxone, you are giving the naloxone wrong. You give just enough to restore respiratory drive, and no more. That way they slowly correct their hypoxemia and hypercarbia while they are still sleeping, and they don't have the huge sympathetic surge that can actually be life-threatening. Hitting someone with 2mg of naloxone right off the bat is a medication error, and the predictable result of that toxic dose of naloxone is an unhappy, puking, hypertensive patient.

Naloxone isn't a reliable reversal for benzos. You can find small studies and case series showing that all kinds of drugs have the ability to antagonize other drugs to some degree, even ondansetron. The effect isn't nearly potent enough or reliable enough to be included in any protocols though.

There's always the option to provide mechanical ventilatory support rather than naloxone, and there's no question that that is sometimes the best option, depending on the scenario. Broadly speaking though, I think properly dosed naloxone is generally a better, safer option. Airway placement has risks (not the least of which is that these patients are at high risk for aspiration) and requires more resources and closer monitoring once at the receiving facility.

Just place a NC and OPA or NPA (or provide ventilations if they are really hypoxemic) and give a small dose (0.1 - 0.4mg) of naloxone every minute or so until they start ventilating better and their Sp02 improves. You now have a calm, sedate patient who is breathing well. Monitor and transport. No versed, ketamine, or LMA needed. Easy peasy.

 

[DrParasite]

Why are you waking up OD patient with Narcan? I thought it was just to restore their respiratory drive.

Titrate till they're breathing, not until they become awake and combative. No need for versed.

 

[Tigger]

Sure, midazolam or ketamine can be used to calm a delirious or angry patient. But there's something about having to sedate a patient whose sedation you just intentionally reversed that should seem wrong on it's face. If your patients are routinely waking up unmanageable after getting naloxone, you are giving the naloxone wrong. You give just enough to restore respiratory drive, and no more.

Why are you waking up OD patient with Narcan? I thought it was just to restore their respiratory drive.

Titrate till they're breathing, not until they become awake and combative. No need for versed.

Unfortunately, with the advent of IN Narcan being available to anyone, we don't always get to control how our patient's receive naloxone. The "non-medical" training is to give 2mg of IN Narcan. There is a change (though less so with IN admin) of that resulting in an agitated patient.

To be clear, I am willing to trade this potential adverse reaction for a patient that is breathing spontaneously prior to my arrival.

 

[Sally Jones]

Sure, midazolam or ketamine can be used to calm a delirious or angry patient. But there's something about having to sedate a patient whose sedation you just intentionally reversed that should seem wrong on it's face. If your patients are routinely waking up unmanageable after getting naloxone, you are giving the naloxone wrong. You give just enough to restore respiratory drive, and no more. That way they slowly correct their hypoxemia and hypercarbia while they are still sleeping, and they don't have the huge sympathetic surge that can actually be life-threatening. Hitting someone with 2mg of naloxone right off the bat is a medication error, and the predictable result of that toxic dose of naloxone is an unhappy, puking, hypertensive patient.

Naloxone isn't a reliable reversal for benzos. You can find small studies and case series showing that all kinds of drugs have the ability to antagonize other drugs to some degree, even ondansetron. The effect isn't nearly potent enough or reliable enough to be included in any protocols though.

There's always the option to provide mechanical ventilatory support rather than naloxone, and there's no question that that is sometimes the best option, depending on the scenario. Broadly speaking though, I think properly dosed naloxone is generally a better, safer option. Airway placement has risks (not the least of which is that these patients are at high risk for aspiration) and requires more resources and closer monitoring once at the receiving facility.

Just place a NC and OPA or NPA (or provide ventilations if they are really hypoxemic) and give a small dose (0.1 - 0.4mg) of naloxone every minute or so until they start ventilating better and their Sp02 improves. You now have a calm, sedate patient who is breathing well. Monitor and transport. No versed, ketamine, or LMA needed. Easy peasy.

BLS used intranssal 2 mg pre-load of Narcan. Titration a bit more difficult with IN route.

 

[Carlos Danger]

BLS used intranssal 2 mg pre-load of Narcan. Titration a bit more difficult with IN route.

That is unfortunate. It's an inappropriate dose, and like any overdose, it will result in problems much more often than if they were able to use a smaller dose.

 

[CANMAN]

Sure, midazolam or ketamine can be used to calm a delirious or angry patient. But there's something about having to sedate a patient whose sedation you just intentionally reversed that should seem wrong on it's face. If your patients are routinely waking up unmanageable after getting naloxone, you are giving the naloxone wrong. You give just enough to restore respiratory drive, and no more. That way they slowly correct their hypoxemia and hypercarbia while they are still sleeping, and they don't have the huge sympathetic surge that can actually be life-threatening. Hitting someone with 2mg of naloxone right off the bat is a medication error, and the predictable result of that toxic dose of naloxone is an unhappy, puking, hypertensive patient.

Naloxone isn't a reliable reversal for benzos. You can find small studies and case series showing that all kinds of drugs have the ability to antagonize other drugs to some degree, even ondansetron. The effect isn't nearly potent enough or reliable enough to be included in any protocols though.

There's always the option to provide mechanical ventilatory support rather than naloxone, and there's no question that that is sometimes the best option, depending on the scenario. Broadly speaking though, I think properly dosed naloxone is generally a better, safer option. Airway placement has risks (not the least of which is that these patients are at high risk for aspiration) and requires more resources and closer monitoring once at the receiving facility.

Just place a NC and OPA or NPA (or provide ventilations if they are really hypoxemic) and give a small dose (0.1 - 0.4mg) of naloxone every minute or so until they start ventilating better and their Sp02 improves. You now have a calm, sedate patient who is breathing well. Monitor and transport. No versed, ketamine, or LMA needed. Easy peasy.

We are seeing this problem all over the state where I am at. Unfortunately pretty much every single city and county is seeing such high overdose rates that the hospitals don't have the patience or resources to continue treatment and monitoring or the patients who are treated as stated above. Baltimore, DC, many of the smaller cities with big drug problems are all giving at times 2 to 4mg of Narcan because if you coast in with a guy who has an NPA and a NC on and have only given 0.8 the first thing the RN's and MD's at all these hospital want to do is give them 2mg and wake them up. This has led to the field provider's in almost every single jurisdiction I am aware of giving 2 to 4mg depending on the substance to get the patient back online and then transporting them. There are city units running upwards of 8 unconscious overdoses a shift and I am not sure in those areas if it's practical to treat as above, especially when the process isn't supported as soon as you roll into the ED. Thoughts?

 

[Carlos Danger]

We are seeing this problem all over the state where I am at. Unfortunately pretty much every single city and county is seeing such high overdose rates that the hospitals don't have the patience or resources to continue treatment and monitoring or the patients who are treated as stated above. Baltimore, DC, many of the smaller cities with big drug problems are all giving at times 2 to 4mg of Narcan because if you coast in with a guy who has an NPA and a NC on and have only given 0.8 the first thing the RN's and MD's at all these hospital want to do is give them 2mg and wake them up. This has led to the field provider's in almost every single jurisdiction I am aware of giving 2 to 4mg depending on the substance to get the patient back online and then transporting them. There are city units running upwards of 8 unconscious overdoses a shift and I am not sure in those areas if it's practical to treat as above, especially when the process isn't supported as soon as you roll into the ED. Thoughts?

Wow. I guess in that case all you can do is what you can do. It sounds like a perpetual MCI.

 

[VFlutter]

Not to condone it but I am sure a lot of that mentality is due to understaffed and overworked ERs. The Nurse to Patient ratios in most busy urban ERs is already woefully inadequate and an OD patient takes up a lot of resources. Especially leaving them in the semi-reversed state with a potentially tenuous airway. The quicker you wake them up the quicker they sign out AMA.

 

[rescue1]

We've been starting with 2mg IV in PA and going up from there. Lots of fentanyl around. Like CANMAN said, if we take them to the ED still unconscious they'll just get 2-4mg as soon as they get a bed (and usually immediately leave AMA). Honestly I've never seen any super bad combativeness that lasts for more than a minute or two, especially if you oxygenate the patient appropriately before they wake up.

(Current record is 14mg in the field --> ICU on a naloxone drip.)

 

[Sally Jones]

We are seeing this problem all over the state where I am at. Unfortunately pretty much every single city and county is seeing such high overdose rates that the hospitals don't have the patience or resources to continue treatment and monitoring or the patients who are treated as stated above. Baltimore, DC, many of the smaller cities with big drug problems are all giving at times 2 to 4mg of Narcan because if you coast in with a guy who has an NPA and a NC on and have only given 0.8 the first thing the RN's and MD's at all these hospital want to do is give them 2mg and wake them up. This has led to the field provider's in almost every single jurisdiction I am aware of giving 2 to 4mg depending on the substance to get the patient back online and then transporting them. There are city units running upwards of 8 unconscious overdoses a shift and I am not sure in those areas if it's practical to treat as above, especially when the process isn't supported as soon as you roll into the ED. Thoughts?

That is closer to what is happening in our area too.

 

[DesertMedic66]

Jeeze. The last time I gave narcan was probably 2 years ago. BVM for a couple of minutes to get SpO2 and EtCO2 normal and then 2mg IN and a 1 minute transport. We don’t get a lot of it here

 

[CANMAN]

Not to condone it but I am sure a lot of that mentality is due to understaffed and overworked ERs. The Nurse to Patient ratios in most busy urban ERs is already woefully inadequate and an OD patient takes up a lot of resources. Especially leaving them in the semi-reversed state with a potentially tenuous airway. The quicker you wake them up the quicker they sign out AMA.

Yup spot on...

 

[CANMAN]

Jeeze. The last time I gave narcan was probably 2 years ago. BVM for a couple of minutes to get SpO2 and EtCO2 normal and then 2mg IN and a 1 minute transport. We don’t get a lot of it here

I give it at least once a shift when on the medic and this is a rural MD county. Units in the city of Westminster I would bet are administering at least 2-3 times a day. It’s crazy and sad.

 

[ParamagicFF]

Wow. I guess in that case all you can do is what you can do. It sounds like a perpetual MCI.

I work in this area and probably 50% of the calls I respond to overdoses of some variety. Generally it is heroin or K2. A day where I don't give narcan is a rarity. It's not uncommon for me to use it 5+ times a tour. I must say, with all of these countless ODs, I have never had anyone wake up violent with me from a heroin OD.

I came from a system where we started IVs and titrated narcan to respiratory drive. In my new system, I did that once and got a reality check from the ER staff. RN gave another 2mg narcan. Physician was by the bedside with "do you want help" paperwork. When the guy wouldn't even admit to drug use and told the doctor to get the f* out of his face, the doctor showed him the AMA paperwork.

Our bed wait times are already long if you aren't a CPR, stroke, MI, or level 1 trauma. We would have to come close to doubling ER capacity if we were transporting all of our heroin overdoses. It's not ideal, but it's the reality. Common practice here is ventilate with BVM, 2mg narcan IM, and let them sign AMA when they wake up and say "I was just tired, I don't do drugs".

 

[VinceVega91]

If they wake up and start to fight, just keep yourself and your partner safe. Defend yourself, leave the scene, or let them leave the scene/truck and then eventually call PD to the scene if you have to. You're their to help these ingrates not fight or sedate them. They're not worth wasting anymore supplies, narcs, or resources. With that being said, double NPAs, 1-2 large bore (EJ) IVs, and repeated rapid sequence Narcan administration is usually the most appropriate care for these truly "sick" patients.

 

[medichopeful]

If they wake up and start to fight, just keep yourself and your partner safe. Defend yourself, leave the scene, or let them leave the scene/truck and then eventually call PD to the scene if you have to. You're their to help these ingrates not fight or sedate them. They're not worth wasting anymore supplies, narcs, or resources. With that being said, double NPAs, 1-2 large bore (EJ) IVs, and repeated rapid sequence Narcan administration is usually the most appropriate care for these truly "sick" patients.

You’re kidding, right? This post is meant to call out providers who actually do that and tell them that’s inappropriate and is an example of what not to do? Right?

RIGHT?!

 

[DrParasite]

double NPAs, 1-2 large bore (EJ) IVs, and repeated rapid sequence Narcan administration is usually the most appropriate care for these truly "sick" patients.

I've seen an EJ put in once in the field.... are you seriously suggestions these patients need one on each side?

 

[VinceVega91]

I've seen an EJ put in once in the field.... are you seriously suggestions these patients need one on each side?

Of course I'm joking. And no we don't do double EJs even though we often suggest the idea. It's just basic medical mischief. We treat these patients accordingly by adequately oxygenating their precious airways and brain cells as well as restoring their consciousness so that we can expedite the rehabilitation process for their "disease".

 

[E tank]

Of course I'm joking. And no we don't do double EJs even though we often suggest the idea. It's just basic medical mischief. We treat these patients accordingly by adequately oxygenating their precious airways and brain cells as well as restoring their consciousness so that we can expedite the rehabilitation process for their "disease".

Hard to say where the sense of gratification comes from for a minority of providers in EMS in being judge, jury and executioner to the patient's they have an obligation to treat. Assuming they even have the competency required to preserve or salvage "precious airways and brain cells" that they think they have, not being able to intellectually separate the provision of lifesaving care from ethical/values/human worth biases is troubling to say the least.

Good families that would otherwise "pass muster" with some of our more sanctimonious colleagues (imagine their relief) lose siblings and children to drug and alcohol addiction every day. It isn't something that happens for the gratuitous purposes of inconveniencing ambulance crews.

If recognizing the humanity of patients is too much of a stretch, consider the professional disadvantages of such an attitude. Not being discrete about such opinions not only makes the person expressing them look like an absolute tool, it reflects poorly on everyone that brings patients to the hospital by ambulance.

And people wonder why EMS workers don't get the respect they deserve.

 

[johnrsemt]

I have had it happen twice in the last 6 months: GCS of 3 (but breathing well on their own), just as we arrive someone gives Narcan internasally (because they are unresponsive, not because they aren't breathing): now they are awake and pissed and combative; but still screwed up enough that we have to transport. So we restrain them to the cot, and away we go; and sometime during the 2 hour transport they are still combative and causing problems in the back. So yes I have given Versed.
Personally I would rather bag them than wake them up that much, but I have bagged someone for 2 hours, and that isn't fun either