45yo Male...Unconscious

[Fox800]

OK how about this.

Does suspected aspiration from OD overdose + questionable respiratory effort and SP02 = endotracheal intubation (not facilitated by medications) before administering naloxone?

 

[triemal04]

Because by reverse logic...prehospital endotracheal intubation isn't indicated just because we suspect the pt. may be going to the ICU...

Ok, that's funny. It is indicated in this situation due to the high likelihood of the airway still being compromised post-narcan though, has nothing to do with going to the ICU.

Cheers. :beerchug:

 

[triemal04]

OK how about this.

Does suspected aspiration from OD overdose + questionable respiratory effort and SP02 = endotracheal intubation (not facilitated by medications) before administering naloxone?

Yes. That's what I'm saying should have been done initially. The pt has vomit around his mouth plus coarse rhonchi in his lungs, low SpO2 with the use of a BVM and OPA, and has OD'd on a narcotic; the "suspected aspiration" should be VERY strongly suspected. He accepted an OPA; intubation shouldn't be very difficult, and, as I keep saying, if you can't raise his SpO2 while bagging him, do you really think it'll change when he breathes on his own? In the given situation you don't need RSI; just tube him.

 

[Fox800]

Ok, that's funny. It is indicated in this situation due to the high likelihood of the airway still being compromised post-narcan though, has nothing to do with going to the ICU.

Cheers. :beerchug:

Haha OK I MAY have been giving you a hard time.

 

[Fox800]

Yes. That's what I'm saying should have been done initially. The pt has vomit around his mouth plus coarse rhonchi in his lungs, low SpO2 with the use of a BVM and OPA, and has OD'd on a narcotic; the "suspected aspiration" should be VERY strongly suspected. He accepted an OPA; intubation shouldn't be very difficult, and, as I keep saying, if you can't raise his SpO2 while bagging him, do you really think it'll change when he breathes on his own? In the given situation you don't need RSI; just tube him.

I understand this. However things were complicated by the fact that SPO2 initially rose after initiating BVM ventilations to around 90%. They did not decline until transporting...about 5 minutes out from the ER. Tough spot to be in.

 

[triemal04]

I understand this. However things were complicated by the fact that SPO2 initially rose after initiating BVM ventilations to around 90%. They did not decline until transporting...about 5 minutes out from the ER. Tough spot to be in.

It is. Again, you just need to be aware of not only what's happening, but what will happen in 5,10,15,20 minutes, and what will happen in 5,10,15,20 minutes if you do what you are about to do. If the SpO2 only had that small an increase after several minutes of bagging (guessing, but if you tried 4 IV's...) it's a good sign something is wrong. If there is rhonchi and signs of vomit it's an even better sign.

Take it as a learning experience; bet the same thing won't ever happen again, will it.

 

[Fox800]

I'm interested to hear what others may suggest as well. We have one vote for bag them to the hospital, and one for intubate prior to trying naloxone.

 

[Aidey]

If the pt responds to narcan, and has a good respiratory drive and can protect his airway, what is intubation after the fact going to help in the short run? The pt has already aspirated, the ship has sailed. Agressive bagging or CPAP runs the risk of pushing the particulate even further into his lungs. If the pt is stable, or stable enough to get to the hospital I would not be that aggressive with them because there is a good chance I'm going to make the pt worse in the long run by being that aggressive.

If I brought an opiate OD RSIed into the ED without first attempting narcan my MD would have my head on a plate. Heck, if I bring in any stable but unresponsive pt RSIed without first trying narcan I would be toast. It's one thing if the pt is crashing and you have to intubate right off to stabilize. It's another to RSI a fairly stable pt first and ask questions later.

This guy had lower O2 sats, and was tachy, but he wasn't crashing. There aren't repeat vitals, but I wouldn't be surprised if his pulse dropped at least some when his O2 sats came up.

Aspiration doesn't mean he is going to end up on a tube and vent either. Yeah, he bought himself an ICU stay, but that doesn't mean he is going to need to be intubated.

 

[MrBrown]

Now that I have thought about it some more; I wouldn't use naloxone.

I would argue it's better to keep this guy down and drop in an LMA, breathe for him and take him to the hospital.

To wake him up with naloxone and have to drop him again to reintubate him seems a bit foolish.

 

[Aidey]

Why is it better for him to be out?

 

[Smash]

Polypharmacy overdose, poor SpO2 despite 100% O2, aspirated, tolerating OPA.

This patient needs to have a number of problems dealt with, and narcan is not going to fix them all. It may not fix any of them given that there is strong suspicion of the pt having had other drugs.

It is unlikely that the patient will need RSI, however I would certainly be prepared for it before I attempted to intubate.

Narcan being given for any unconscious patient irrespective of what is wrong with them just makes we want to cry. Given the history and presentation of the patient it seems reasonably apparent that even if he wakes up we are not going to fix all the problems, and having narcan on board can potentially complicate the course of treatment.

 

[Aidey]

Where is the polypharmacy? There is no evidence that he actually took the Amnitriptyline and the pt responded well to Narcan. It is one thing to intubate after trying narcan and not having any reaction. It is another to just automatically intubate (I'm talking in a stable, or mostly stable patient here).

I'm not advocating narcan first in every unconscious patient. I'm saying that in stable patients, it is better to try narcan first, rather than intubate, which has a lot more complications than narcan administration.

From the information given the pt has 3 problems. 1. A mental illness (amnitriptyline RX) 2. Chronic IV drug use. 3. Acute aspiration second to ALOC. What problem is the narcan going to aggravate? The aspiration isn't going to change whether the pt is breathing on his own or we are breathing for him. The only complication I see is that he may not be as cooperative as he was while knocked out.

What benefit is intubation going to have for this patient?

 

[Akulahawk]

Hmm. Patient accepts an OPA, has vomited, likely aspirated... and isn't getting all that good of an increase in SpO2 with bagging? While normally giving naloxone to an OD patient might be a good idea, to me, I'd rather intubate him and forego the naloxone to better protect his airway. If he's vomited and aspirated once, what's to say he won't vomit and aspirate more? If he hadn't vomited and aspirated, I'd consider sticking with BLS airway management until the naloxone took effect.

 

[Fox800]

Let me clarify the pt.'s response to treatments.

Initial SPO2 on arrival was around 85%. With a BVM, it rose to 95+%. This rise from 85% to 95% happened in a normal/respectable time interval, maybe 2-2.5 minutes.

Naloxone administered IM. Pt. awakens to GCS 14. By this time, about ten minutes had elapsed between initial airway management, IV attempts, blood glucose measurement, 12-lead acquisition, naloxone administration, positioning the stretcher, etc. Pt. moved to stretcher, SPO2 drops to ~90%.

Transport code 3. En route, SPO2 declines to 65-75% despite assisting ventilations. Pt. remains awake and responsive to verbal stimuli, he is able to follow commands.

I'm on the same page as Aidey. If I intubate a suspected/possible opiate overdose with signs of respiratory depression without trying naloxone, the ER physician and my medical director are going to have my a@$.

 

[Fox800]

Polypharmacy overdose, poor SpO2 despite 100% O2, aspirated, tolerating OPA.

This patient needs to have a number of problems dealt with, and narcan is not going to fix them all. It may not fix any of them given that there is strong suspicion of the pt having had other drugs.

It is unlikely that the patient will need RSI, however I would certainly be prepared for it before I attempted to intubate.

Narcan being given for any unconscious patient irrespective of what is wrong with them just makes we want to cry. Given the history and presentation of the patient it seems reasonably apparent that even if he wakes up we are not going to fix all the problems, and having narcan on board can potentially complicate the course of treatment.

Naloxone was certainly indicated and reasonable in this circumstance. You have a pt. with a history of IV drug use (probably heroin/opiates), who is unconscious with profound respiratory depression. I don't believe in "coma cocktails" and don't give naloxone to unconscious patients with adequate respiratory drives.

I don't think anyone here expects naloxone to fix "all of the patient's problems" but it would reasonably help to resolve immediate life threats of 1. Bradypnea, 2. Poor tidal volume, 3. Airway compromise secondary to unconsciousness

 

[Aidey]

One question, why were ventilations still being assisted?

If a patient reacts well to narcan, and has a GCS of 14, how is intubation going to protect their airway any better than they can? That is what I'm not getting here.

Sure the pt can still vomit, but people vomit all the time. I don't RSI all of them just for that.

This topic is a hot button for my MD. His feelings on it are that on one hand you are treating the problem and reducing or eliminating the risk of complications while on the other you are performing a dangerous procedure that can cause multiple complications and isn't actually fixing anything, just providing marginal protection.

That being said, he also hates people who slam all 2mg of Narcan at once. On the flip side he also says if your pt is crashing, tube them now before it gets harder later. I've RSIed two OD patients while under his direction. In both cases we somehow managed to administer narcan before intubation without delaying the intubation. We used an MAD while getting everything ready.

 

[Fox800]

Now that I have thought about it some more; I wouldn't use naloxone.

I would argue it's better to keep this guy down and drop in an LMA, breathe for him and take him to the hospital.

To wake him up with naloxone and have to drop him again to reintubate him seems a bit foolish.

Why is it better for him to be out?

I'd also like to hear the reasoning for this. I'm not a big fan of placing a rescue airway device (Combi-Tube, King LTS-D, LMA) to compensate for a pt.'s unmaintained airway when we can administer a medication to potentially reverse that.

 

[Fox800]

One question, why were ventilations still being assisted?

If a patient reacts well to narcan, and has a GCS of 14, how is intubation going to protect their airway any better than they can? That is what I'm not getting here.

Sure the pt can still vomit, but people vomit all the time. I don't RSI all of them just for that.

Ventilations were assisted due to the fact that the pt. was still exhibiting altered mental status, had poor lung sounds, was responding to verbal stimuli (not "alert") and had poor pulse oximetry and capnography values (SPO2 65-75% and ETCO2 55-65mmHg).

 

[Aidey]

How well was he tolerating that? A GCS of 14 is awfully high to tolerate override bagging.

 

[Fox800]

How well was he tolerating that? A GCS of 14 is awfully high to tolerate override bagging.

He was able to be coached through it. Always a joy trying to bag conscious patients.