Acute withdrawal syndrome...

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Speedylifsavr

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Just wanted to share a recent call I ran and get your opinions on narcan administration and what your protocols dictate .

Dispatched to cardiac arrest in a vehicle . I arrive on scene to find approximately 30 y/o female slumped over in her vehicle in a parking lot space with no visible damage . I sit her up and immediately notice she is very cyanotic , agonal respirations and cannot palpate a pulse , possible code . After a quick extrication , lay her supine on a backboard , do a quick jaw thrust and am able to detect a thready carotid . Start thinking OD , I control her airway O2/BVM/OPA and insert an 18g R EJ .

Pt has no visible track marks but an empty unlabeled prescription bottle was found in the vehicle . I suspect opioids or methadone....dont know why , just a gut . Blood glucose 170 . Our protocol for narcan is 2mg slow IV push . I administer .5 , then another .5.....and I see an very nice turnaround with my patient . RR increases 18 , skin dries up , she's nice and pink , spo2 100% and am able to place her on NRM and remove opa after some slight gagging .

At this point I start remeniscing about prior OD's and consider acute withdrawal syndrome . We are about 10min's out so I advise my partner to initiate transport . My rationale is If i adminminister the other 1 mg I am going to "awaken the beast" . I have run countless other OD's where I've given the narcan 2mg without a 2nd thought...but this one I had reservations , I deeply suspected acute withdrawal syndrome .

I called med control to relay my thoughts hoping they would understand my plea until I got the pt to a more controlled environment (ER) . I was rudely answered by a snappy nurse on the other end , who I just explained my suspicions to , who simply states "is there any reason you are not following your protocol?"...I then ask to speak to a DR...she comes back and says the DR wants you to treat per your protocol . She probably didnt even explain it to him .

Well....I administer the other 1mg....and the demon awoke.....thrashing , yelling , seizures , posturing , spitting and projectile vomit (her last meal was obviously chocolate doughnuts....gross)... I am in the back of the rig by myself , I control her airway best i can with suction . Luckily we arrive at the hospital and it takes a team of 7 doctors , nurses and techs to subdue her , medicate her and RSI her .

I really think with an understanding ear this all could have been avoided .I didnt get a chance to find out who the nurse on the radio was as we had to quickly clean up and get back in service .


What do you guys think? What do your protocols dictate?....ever experienced an nasty withdrawal?
 
Here's what our protocols say
  2. [FONT=Arial, sans-serif]If patient is apneic, or suspected to become uncooperative and/or violent, consider [/FONT][FONT=Arial, sans-serif]naloxone[/FONT][FONT=Arial, sans-serif], administered by titrating to a return of respiratory drive and to a point where the patient can be managed.
    [/FONT]
  3. [FONT=Arial, sans-serif]Administer [/FONT][FONT=Arial, sans-serif]naloxone,[/FONT][FONT=Arial, sans-serif] 1 – 4 mg, IV bolus or IM.
Click to expand...
  1. [/FONT]
 
Where do you work?
 
I'm just a medic student and I have never given narcan my self, but I have been told to give the med in 0.2mg doses every 2 or 3 minutes X 3 doses then give a 1.4mg push. My instructor told us not to "slam it home" because it will wake the beast and you end up with vomiting and a fight.
 
I was always told, "if you need to speak to a doc, then ask for one up front and don't use a messenger."

Local protocol: B/IV, I, P

8 years old to Adult:
titrated up to 2.0 mg IV bolus or IN (may also be given IM or IO, if needed). Repeat dose of 2.0 mg may be given if no response is noted after 5 minutes.
 
Narcan. Slow IVP. Once breathing is controlled and vitals improve even slower IVP. Final IVP as you pull up at the ER door. You complied with protocol and they can clean the mess and have enough people to restrain her as she fights.
 
Protocols are only suggestions. I personally would had held the remainder as well. Any physician of any caliber would agree too. If not, simple.. with a B.S. response I would had ignored and told them the radio must have broken up or if I wanted to be a pr*ck, administered the rest as I was unloading the patient onto the stretcher (especially if it was the nurse on the radio) stating.. "protocol finished".

Sorry, verbal orders comes with a Doc's name and who gave the reporting order. Surely, there is some form of documentation they have to fill out if not there should be.

R/r911
 
ffemt8978 said:
Here's what our protocols say
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[/LIST]
Click to expand...

This is a great protocol . I am going to speak with our medical director see if we cant make some changes to our current protocol .

I work for a County EMS service in FL .
 
Last edited by a moderator:
Speedylifsavr said:
I work for a County EMS service in FL
Click to expand...

Hmm. That explains quite a bit.

No offense bro, but I did my Medic down there, and I was far from impressed.

Our standing orders allow for up to 2 mg, titrated to the pts condition.

There are times you need to use your clinical judgement when treating the patients. You follow the cookbook, without a critical thought, and bad stuff happens.

To echo Rids thoughts, you want a doc, you ask for one, and you get his name for your report.
 
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