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Thread: Narcan (Naloxone) Training

  1. #91
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    Quote Originally Posted by 1168 View Post
    “by the time the Narcan is handy we have enough people on hand that a wrestling match won't be an issue.”

    Is this group of people all going on the transport, or does a single paramedic have to ride in the back of the bus with a combative patient?

    “We're not titrating just enough to get the breathing going again, we just administer the whole thing.”

    This is one of the reasons I hate first responders giving Narcan.
    Method of transport and number of people in the back would depend on where the incident occurred, and the patient's condition and demeanor. It could be an ambulance or helicopter, and there may be an officer in back or not, depending.

    Do you think it's better to just ventilate, vs administering enough narcan that the patient wakes up?

  2. #92
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    Quote Originally Posted by p.. View Post
    Method of transport and number of people in the back would depend on where the incident occurred, and the patient's condition and demeanor. It could be an ambulance or helicopter, and there may be an officer in back or not, depending.

    Do you think it's better to just ventilate, vs administering enough narcan that the patient wakes up?
    Unless the ALS unit is greater than 15 minutes out, yes. And if you are giving Narcan, the objective should be to restore adequate respirations, not wake the patient. Keep in mind that the medic is going to have to deal with this guy after you cause vomiting and withdrawal. Follow your local protocols, of course, but I would rather First Responders not give any patients drugs of any sort, except oxygen, epi, glucose, or aspirin as appropriate.

    The majority of opioid OD’s I attend have adequate respirations and reasonable SpO2, ETCO2, etc. They are just somnolent. Which is not really an overdose, so much as the target effect for the junkie, but whatever.

    Actually, lemme rephrase that: Many of the “OD’s” I attend are not opioid overdoses at all. Your area may differ.
    RLTW

    “That is why there isn't an AK chart.” -SteyrAUG
    “They eat tide pods also so what's your point?” Retrorevolver77

  3. #93
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    Quote Originally Posted by 1168 View Post
    Unless the ALS unit is greater than 15 minutes out, yes. And if you are giving Narcan, the objective should be to restore adequate respirations, not wake the patient. Keep in mind that the medic is going to have to deal with this guy after you cause vomiting and withdrawal. Follow your local protocols, of course, but I would rather First Responders not give any patients drugs of any sort, except oxygen, epi, glucose, or aspirin as appropriate.

    The majority of opioid OD’s I attend have adequate respirations and reasonable SpO2, ETCO2, etc. They are just somnolent. Which is not really an overdose, so much as the target effect for the junkie, but whatever.

    Actually, lemme rephrase that: Many of the “OD’s” I attend are not opioid overdoses at all. Your area may differ.
    Yes, the objective is to restore breathing. Waking them up for us is essentially a side effect.

    FWIW, these are our current protocols for naloxone. The nasal injectors may be used down to the EMR level at my agency. Our medical director and EMS coordinator have us just using preloaded Narcan brand units, which is fine with me as we are primarily SAR and often perform treatment after swimming to the patient, so making things simpler and less fiddly is great. I'm generally not working in a parking lot next to the open doors of an ambulance while wearing a pair of blue Dickies and 511 zipper boots. More likely, I'm wearing a wetsuit and a pair of fins with a little seaweed draped over my ear.

    I see that vomiting is mentioned in our Paramedic protocol, but not the EMR/EMT protocol. Have you only seen vomiting when giving narcan IM/IO, or have you also seen it when given IN?

    Scope EMR, EMT
    Class Narcotic Antagonist
    Action Competes with opiates for receptor sites in the brain that affect pain and breathing,
    thereby reversing the respiratory and CNS depressant effects of opiate drugs.
    Onset IN 3-5 minutes
    Peak Effect 20 minutes
    Duration 1- 2 hours
    Indications Suspected opiate intoxication (pinpoint pupils, decreased respiratory rate, drug
    paraphernalia) with depressed mental status AND apnea or slow shallow breathing.
    Contraindications Infants less then 28 days old, Known allergy to naloxone
    Side Effects Causes opiate withdrawal in patients with opioid addiction/chronic exposure (anxiety,
    agitation, piloerection, body aches, diarrhea, diaphoresis, yawning)
    Rare - Pulmonary edema, acute myocardial infarction, ventricular arrhythmias
    Form Ampule: Various sizes: 1mg, 2mg, 10mg
    Preload: 2mg in 2ml
    Dosage See Mucosal Atomizer Device (MAD) Procedure for administration of IN dosing
    > 10-Adults: IN: 2mg every 5 minutes prn ALOC (max 10mg)
    < 10 yrs: IN: 0.1mg/kg (max 2mg per dose) every 5 minutes (max 10 mg)

    Notes If 10mg of naloxone is given and there is no response, then ALOC is unlikely due to
    opiates (Other considerations- hypoglycemia, head injury, hypothermia, hypoxia,
    shock, stroke)

    Pinpoint pupils are the classic sign of narcotic use/overdose, but with multi-drug
    intoxications, pupil findings may be variable.

    Naloxone has NO side effects in the absence of opiates or opiate addiction. It is
    remarkably safe, so do not hesitate to use if indicated.

    Naloxone has a shorter duration than many opiates, so observe closely for re-sedation
    and repeat doses as necessary. Also, important to strongly discourage patients who
    attempt to sign out against medical advice as life threatening symptoms may return as
    naloxone wears off.

    Some agents (e.g. Fentanyl) may require higher than usual doses for reversal.
    For paramedics (we are almost exclusively EMTs; the only medic curently at my duty location is the EMS coordinator):

    Scope Paramedic
    Class Narcotic Antagonist
    Action Competes with narcotics for opiate receptor sites in the brain that affect pain and
    breathing, thereby reversing the respiratory depressant effects of narcotic drugs.
    Onset IV/IO: 2 minutes
    IN/IM: 5 minutes
    Duration 1- 4 hours
    Indications Suspected narcotic intoxication with altered mental status AND apnea or slow shallow
    breathing.
    Contraindications None
    Side Effects Acute withdrawal syndrome in patients addicted to opiates (pain, nausea, vomiting,
    diarrhea, hypertension, tachycardia, tremors).
    Form Ampule: Various sizes: 1mg, 2mg, 10mg
    Preload: 2mg in 2ml
    Dosage IN Route preferred
    > 10-Adults: IN/IM: 2mg every 5 minutes prn ALOC (max 10mg)
    IV/IO: 2mg every 2 minutes prn ALOC (max 10mg)
    < 10 yrs: IN/IM: 0.1mg/kg (max 2mg per dose) every 5 minutes (max 10 mg)
    IV/IO: 0.1mg/kg (max 2mg per dose) every 2 minutes (max 10 mg)

    Notes Pinpoint pupils are the classic sign of narcotic use/overdose, but with multi-drug
    intoxications, pupil findings may be variable.

    Naloxone has no side effects in the absence of narcotics. It is remarkably safe, so do not
    hesitate to use if indicated.

    Naloxone has a shorter duration of action than many narcotics, so observe closely for re-
    sedation. Repeat doses may be necessary.

    Some agents (e.g. Darvon, Fentanyl) may require higher than usual doses for reversal.

  4. #94
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    I dont think it will promote drug abuse, because ( as I understand it) when an addict OD's, and then gets Narcane the addict goes into severe withdrawal. Because it nullifies all drug in the system. I had a friend that did it and he said it was the worst experience of his life. Not something that drug addicts want IMHO.

    I know opinions may vary, just my .02.

    PB
    "Air Force / Policeman / Fireman / Man of God / Friend of mine / R.I.P. Steve Lamy"

  5. #95
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    Quote Originally Posted by p.. View Post
    Yes, the objective is to restore breathing. Waking them up for us is essentially a side effect.

    FWIW, these are our current protocols for naloxone. The nasal injectors may be used down to the EMR level at my agency. Our medical director and EMS coordinator have us just using preloaded Narcan brand units, which is fine with me as we are primarily SAR and often perform treatment after swimming to the patient, so making things simpler and less fiddly is great. I'm generally not working in a parking lot next to the open doors of an ambulance while wearing a pair of blue Dickies and 511 zipper boots. More likely, I'm wearing a wetsuit and a pair of fins with a little seaweed draped over my ear.

    I see that vomiting is mentioned in our Paramedic protocol, but not the EMR/EMT protocol. Have you only seen vomiting when giving narcan IM/IO, or have you also seen it when given IN?



    For paramedics (we are almost exclusively EMTs; the only medic curently at my duty location is the EMS coordinator):
    Yes, I have seen the same side effects that IV naloxone comes with when given IN, including vomiting. Just takes a couple minutes.

    In your setting Narcan makes sense, because the victim may need to assist in his own rescue.
    RLTW

    “That is why there isn't an AK chart.” -SteyrAUG
    “They eat tide pods also so what's your point?” Retrorevolver77

  6. #96
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    Good to know. Thanks for the heads up.

  7. #97
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    Quote Originally Posted by 1168 View Post
    The majority of opioid OD’s I attend have adequate respirations and reasonable SpO2, ETCO2, etc. They are just somnolent. Which is not really an overdose, so much as the target effect for the junkie, but whatever.

    Actually, lemme rephrase that: Many of the “OD’s” I attend are not opioid overdoses at all. Your area may differ.
    Same.

    As an urban medic, I see significantly more doses than overdoses. I haven’t had to give much Narcan, truth be told, and a lot of my “OD” calls are third party callers when their white guilt kicks in and they see some rooter zonked out beside a gas station. Most are just dosed- sleepy and breathing. Recently, my legit ODs have almost all been in cardiac arrest because nobody called until they woke up and found their buddy dead. Sad situation, but it was their lifestyle and it has consequences.

    On the topic of street drugs- I’ve had to give more Versed for crack/cocaine induced chest pain than Narcan, for sure. My friends at other agencies (particularly in the more rural counties around the metro area) run more opioid calls, I get a lot of cocaine/MDMA/GHB. My opioid calls are frequently in the more affluent areas of the city, and many aren’t IVDUs, they just blow their heroin or take pills.

    *ETA: I know I’ve posted in this thread before, but in the 2 years since I originally posted, I’ve gained more experience and a different outlook to handling recreational drug overdoses. Of note, I have seen minimally trained bystander and LEO Narcan use increasing in the past 6ish months, and most all of them were in appropriate situations that were of benefit to the Pt.
    Last edited by GTF425; 12-02-19 at 12:50.

  8. #98
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    Quote Originally Posted by GTF425 View Post
    Same.

    As an urban medic, I see significantly more doses than overdoses. I haven’t had to give much Narcan, truth be told, and a lot of my “OD” calls are third party callers when their white guilt kicks in and they see some rooter zonked out beside a gas station. Most are just dosed- sleepy and breathing. My legit ODs are usually in cardiac arrest because nobody called until they woke up and found their drug buddy dead.

    On the topic of street drugs- I’ve had to give more Versed for crack/cocaine induced chest pain than Narcan, for sure. My friends at other agencies run more opioid calls, I get a lot of cocaine/MDMA/GHB.
    You got me thinking about the last time I gave someone Narcan, so I did a review of my charts and applied some filters in ESO. It was 783 patients ago, 0.5mg IV. Call went out as cardiac arrest. She was having a drug nap on the recliner. Honestly, probably would have done fine without it.
    Last edited by 1168; 12-02-19 at 12:53.

  9. #99
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    Quote Originally Posted by 1168 View Post
    783 patients ago
    What part of the country are you in? I realize recreational drugs are somewhat region-specific, and in some places (touristy areas) change with the seasons.

    First time I attended an opioid OD was off duty, I think about 2015, in New England. Drove past a ~20 y/o girl laying on the sidewalk with what looked like someone doing chest compressions on her, so I pulled over and hopped out to help. Had a pulse, agonal breathing, cyanotic, unresponsive. An especially strong batch of heroin had hit the region, likely one of the first times fentanyl was cut in to the local supply, and ~30 people in the area ODed that month with I forget how many deaths. All I did was ventilate with an on-duty cop who showed up right after with a BVM in his kit, we were there a few minutes working on her, and the first on duty EMS that showed up got out of his truck with a narcan nasal injector in his hand when he stepped out. They were just running OD call after OD call.

    Where I work on the west coast, at the time, none of the EMS trainers had actually seen a heroin OD yet or had actually administered narcan yet. They were all dealing with meth, cocaine, other stuff. But it's finally there now too.

  10. #100
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    Quote Originally Posted by p.. View Post
    What part of the country are you in? I realize recreational drugs are somewhat region-specific, and in some places (touristy areas) change with the seasons.


    An especially strong batch of heroin had hit the region, likely one of the first times fentanyl was cut in to the local supply,

    ... New England... the first on duty EMS that showed up got out of his truck with a narcan nasal injector in his hand when he stepped out.
    Charleston metropolitan area.

    I don’t think we have much (car)fentanyl here, just regular heroin and scripts, along with all the other street drugs.

    New England is on a different level.
    RLTW

    “That is why there isn't an AK chart.” -SteyrAUG
    “They eat tide pods also so what's your point?” Retrorevolver77

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