Administration of Narcan for AMS

[Summit]

Narcan competes for receptor sites, but isn't shown (not that I am aware at least) to produce any effects once it binds to the receptors in the absence of an opiate.

That's a very simplistic assumption of patient state. Image opioid countering poly pharmacy of the stimulant variety? Or chronic pain state now out of control!


Here are adverse reactions:
http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/r?dbs+hsdb:@term+@rn+465-65-6

Most related to post surgical but many are potentially applicable pre hospital.

If you have no indication that a treatment it's needed, how might it hurt is every bit as important a question as how might it help. That is before you ask cost. If everything is equal it is considered best not to act in medicine unless you are desperate.

Back in the 80s using narcan to suppress endogenous opioids that use those receptors in shock states was thought to be the next great use of narcan. But it didn't work and the risk wasn't worth "doing it just in case" not to mention cost.

 

[phideux]

It's not like you're giving it for every healthy person. It's just a last ditch effort before having to Intubate. It's worked several times for me but I guess to each his own

The OP stated that the respiratory drive wasn't depressed, why would you even be considering dropping a tube???

 

[chaz90]

The OP stated that the respiratory drive wasn't depressed, why would you even be considering dropping a tube???

Barely responsive to painful stimuli, excessive salivation, no intrinsic effort to clear her own airway, posturing, "near trismus" with inability to completely access the airway, and ~1 hr. transport time by ground.

Yeah, I'm absolutely going to RSI this patient.

 

[ERDoc]

This is exactly the reasoning why I would give Narcan. I do realize it isn't likely an opioid, without the ability to run a tox screen, you can't absolutely rule it out. With that, Narcan should be considered as a later treatment possibility when everything else has been done.

A tox screen is useless and should not change your management. All it tells you is what the pt has taken in the last few days, not what is causing the acute issue. Narcan, and any medication for that matter, should only be given if there are clinical indications to give it. I haven't read the original scenario so I can't say if I would give it or not, but from the sounds of it, probably not.

Ever see a chronic pain patient get narcan when they don't need it?

Come on most borderline opiate od (anything occult is borderline) can be solved with some bagging until they clear up unless outs it's mscontin or a patch which you can find and remove.

Profound od needs the narcan.

This is the part that EMS doesn't get to see. Doing something in the ambulance can have huge consequences downstream. There was recently a case here where EMS picked up a pt on chronic, high dose opiates from a nursing home (we won't even get into that part) who was altered. The pt was not given any additional meds over her normal meds and did not have access to anything she wasn't prescribed. This crew hit this poor 60 something woman with 4mg IV narcan. After they drop her off she develops horrible withdrawal (heart rate in the 150s, RR in the 30s, agitated, combative, pupils were huge) and she was no more lucid than she was when she arrived. She was given massive amounts of dilaudid and ativan. She ended up being intubated when she started to tire. The admitting service tried putting a subclavian line in and dropped her lung. She then required a chest tube. So, this woman who was not a narcotic overdose was given a medication than doesn't do any harm because, "hey, it couldn't hurt," and ended up in opiate withdrawal, intubated and with a central line and chest tube, none of which probably would have been needed in the first place if the narcan was not given.

Never say a medication doesn't have a downside. They all do and the effects can be disastrous.

 

[CALEMT]

I know I'm just the EMT posting in the super cool ALS forum, but since when do you give medications that aren't clinically indicated? I thought for narcan you need opioid OD with a decreased respiratory drive. Since when do we (providers) give medications just to rule something out?

 

[StCEMT]

That's a very simplistic assumption of patient state. Image opioid countering poly pharmacy of the stimulant variety? Or chronic pain state now out of control!


Here are adverse reactions:
http://toxnet.nlm.nih.gov/cgi-bin/sis/search2/r?dbs+hsdb:@term+@rn+465-65-6

Most related to post surgical but many are potentially applicable pre hospital.

If you have no indication that a treatment it's needed, how might it hurt is every bit as important a question as how might it help. That is before you ask cost. If everything is equal it is considered best not to act in medicine unless you are desperate.

Back in the 80s using narcan to suppress endogenous opioids that use those receptors in shock states was thought to be the next great use of narcan. But it didn't work and the risk wasn't worth "doing it just in case" not to mention cost.

I don't know what the patient state is in this case. I am not unaware of the potential issues associated with chronic pain.

That was actually a pretty interesting link, thanks for sharing.

Again, I don't know what patient state is so it may or may not be indicated. I went and looked at my book though. The two indications I had in mind from the reading are ALOC and coma of unknown origin. Which is why depending on the situation, indications I've been given, and prior experience of others it wasn't something ruled out immediately for me. Based on what indications I had been given in the text, it seems like something to keep reserved until an earlier treatment has some positive effect or I find another reason to rule it out (coma origin becomes known etc.). That being said, I am by no means saying give out Narcan to anyone and everyone "just cuz".

 

[DesertMedic66]

I love that my county's protocols do not even mention ALOC as a consideration for Narcan (I don't like the dosage we have to do)

 

[FiremanMike]

I love that my county's protocols do not even mention ALOC as a consideration for Narcan (I don't like the dosage we have to do) View attachment 2596

Mine does

1. Unconscious/Unknown - sugar > 60, give narcan
2. CVA/Unconscious - In patients with decreased LOC of unknown etiology
3. Narcan - Indications -> unconscious/unknown

Although, all three pages say to only give enough to "maintain adequate respirations".

Overall I would consider our protocol to be progressive and our medical director to be hands-on and involved, so it's not a matter of having a weak protocol.

 

[Tigger]

For me to give a patient narcan the patient needs to have respiratory depression. The patient in the scenario is has a compromised airway but is not depressed. I do not believe those to be the same thing. Also, her pupils were fairly large.

 

[medicsb]

I prefer to have a good, solid indication for narcan (empty bottle of percocet or a needle in the arm are preferred). But, there have been situations where it was questionable and narcan administration saved the patient from a. intubation and/or b. an expensive work-up for altered mental status. I prefer small doses 0.4-0.5mg at a time, so I have not had anyone spiral in to some terrible withdrawal so far. Typically if I do this it's because they're stable (i.e. everything in normal ranges), relatively healthy (few minor problems or no PMHx), without signs of trauma, euglycemic, etc... as in there is no immediately identifiable cause for their comatose state. I'd say that the more comorbidities and the older they are, the more I'm going to need strong evidence of opiate intoxication.

 

[FiremanMike]

I would be curious to hear what demographic you guys work in. Perhaps socioeconomic strata becomes a factor that raises and lowers our respective index of suspicion and leads us to be more or less likely to administer narcan?

 

[Doczilla]

You guys remember the old "coma cocktail"? Everyone with AMS got thiamine, D50 and narcan.

I think people still try to titrate to "awake" (read: combative, piss and vomit covered, etc), when the paradigm has shifted to respiration-driven administration.

If they're "altered" with adequate respirations, leave them alone (aside from searching for more insideous causes of AMS). I think this is especially true in polypharmacy, where removing one component while leaving the other one unopposed can have deleterious effects. Like ERdoc said, they often have to get REsedated later. What did we accomplish for them?

Edit: Spelling

 

[Tigger]

You guys remember the old "coma cocktail"? Everyone with AMS got thiamine, D50 and narcan.

I think people still try to titrate to "awake" (read: combative, piss and vomit covered, etc), when the paradigm has shifted to respiration-driven administration.

If they're "altered" with adequate respirations, leave them alone (aside from searching for more insideous causes of AMS). I think this is especially true in polypharmacy, where removing one component while leaving the other one unopposed can have deleterious effects. Like ERdoc said, they often have to get REsedated later. What did we accomplish for them?

Edit: Spelling

Yes. If they are adequately breathing we just transport and provide supportive care. I don't feel as cool when I walk in and have no idea what is going on, but that's just the reality sometimes.

 

[Tigger]

Yes. If they are adequately breathing we just transport and provide supportive care. I don't feel as cool when I walk in and have no idea what is going on, but that's just the reality sometimes.

I would be curious to hear what demographic you guys work in. Perhaps socioeconomic strata becomes a factor that raises and lowers our respective index of suspicion and leads us to be more or less likely to administer narcan?

I work through a midsized city all the way to the super boonies. Same procedure.

 

[gotbeerz001]

I would be curious to hear what demographic you guys work in. Perhaps socioeconomic strata becomes a factor that raises and lowers our respective index of suspicion and leads us to be more or less likely to administer narcan?

Oakland, CA... We give Narcan for respiratory depression with suspected narcotic OD. Our ALOC protocol directly states DO NOT administer Narcan in the absence of respiratory depression.

Plenty of "socioeconomic strata" here.

 

[DesertMedic66]

I would be curious to hear what demographic you guys work in. Perhaps socioeconomic strata becomes a factor that raises and lowers our respective index of suspicion and leads us to be more or less likely to administer narcan?

We cover a vast amount of areas that include multi million dollar houses, housing tracks where the individual net worth has to be over 5 million to live there, the ghetto where drug deals are going down across the street and the homie drop offs at the police/fire/EMS station, the small communities at least an hour away from anything, and several farming communities.

 

[Flying]

We cover everything from the big urban college town to generic New Jersey suburbia to a few of the top zip codes in income.

 

[NomadicMedic]

Huge military base, town of about 60,000 and a lot of rural. I don't dispense Narcan based on ZIP Code or how much money they have in their pocket. They get it (or don't) based on respiratory drive.

 

[Chewy20]

Do you also give epi when someone is stung by a bee and shows no signs of anaphylaxis?

You could ask the same question about any drug when its not actually indicated. Listen to how stupid that sounds.

 

[FiremanMike]

Alright, the socioeconomic question was meant to elicit discussion, no reason to start posturing.

I do believe we are being a little bit too "all or nothing" with the stance that respiratory depression is the end-all, be-all decision maker for the administration of narcan. Altered LOC, in and of itself, can have its own set of issues and potential necessity for reversal. Is the patient so far unconscious that self maintenance of their airway may become an issue? Is there a potential for opiate use and/or abuse? Is the administration of narcan better for these patients than securing their airway? If the above answers are true, then why does a respiratory rate of 12 drive your decision making process?

None of the questions I asked have absolute answers, and neither should your approach to your patient. Certainly unconsciousness with respiratory depression and friends saying "he used heroin" will bring me to narcan more quickly, but an absence of respiratory depression certainly doesn't take narcan completely off the table, in my book.