Narcan and hypotension

[firemedic31075]

Ran a call a few weeks ago for an overdose of oxycodone and Xanax. We arrived to find a 40 y/o/f lying on the floor unresponsive breathing about 6-8 times per min. Airway initially controlled with OPA and ventilated @ 12xmin. No radial pulse but good carotid, skin is cool, pale and diaphretic. pupils-pinpoint. HR- 118 EKG - b/p- 74/40 Sinus Tach. LS- clear and Equal bilat. Accucheck-108.Hx-depression . Meds- Xanax.. After admin of narcan IM pt. began gagging slightly. Pt. was RSI'd in back of unit (Etomidate and Sux). Normal Saline bolus 500ml. The lead medic begins giving narcan throughout transport, unknown to me and tells me later that we still needed to reverse the opiate induced hypotension.

I know narcan reverses resp. depression. But will it reverse the hypotension?

I didn't think it would but I could be wrong.

 

[Aidey]

If the patient was still hypotensive post narcan, it was probably caused by the xanax, not the hydrocodone. Narcan reverses all opiate affects, and as long as a sufficent dose of narcan was administered to counteract the hydrocodone the patient wouldn't continue to be hypotensive because of it.

Some long acting opiates, like methadone, need very high doses of narcan repeated over time to reverse all the affect, but with hydrocodone the affects should have been reduced (if not eliminated) by the initial narcan dose, assuming it was at least a couple of MG or higher.

Xanax on the other hand can cause a lot of side effects when taken in exess. I had a xanax OD a while back where the person took about 90mg of Xanax and ended up in the ICU for 3 days on a vent.

 

[DV_EMT]

just asked my pharmacist about it...

It will only reverse it if it's opiate induced hypotension.

But speaking of stoopid people who decide to OD. Had a friend who told me that she took 4-5 xanax with a bunch of shots..... and wanted to use MY jacuzzi. Of course my rxn was, "no way in heck that I'd let that happen, I don't want a corpse in my jacuzzi!!"


regardless... she ended up in the ER later that night... :/

job security anyone??

 

[Aidey]

I forgot to add that Xanax isn't an opiate. It's a benzo, which is the same family as valium and versed. Its effects can be reversed with romazicon/flumazenil (sp?), however there is a risk of inducing seizure with it, which is why you don't see it used commonly pre-hospital (or at least I haven't seen it available pre-hospital much).

 

[maxwell]

If the lowpertension was d/t narcos, then the naloxone will reverse them. It is important to say that narcan is NOT a vasopressor, nor does it reverse alprazolam. For that you'll need flumazenil, also not a pressor.

 

[Aidey]

The patient may not need a pressor once the effects of the meds have been counteracted.

 

[Ridryder911]

I ask why was the Narcan given IM as appearantly you were able to RSI? As well as discussed, there is still a lot of what we do not know about Narcan, too. As discussed in overdoses of Clonidine on why it has a percentage chance of working sometimes but not always (as there are theories of why it works).

True it is for opoid products, it may be effective on other medications as well.


R/r 911

 

[Aidey]

Rid, do you know of any credible studies that have been done on its affects on other medications? Like you mention, there are plenty of anecdotal reports of it affecting other meds, but I'm curious about how much that has been studied.

 

[Ridryder911]

Sasha, asked me about Clonidine and Narcan and was able to find some info on lit research. There are some theories of why, as in related to the "blocking action" it might work upon this medication but as I described it is not a certain.

I found two or three published reports rather easy r/t human studies and several r/t bovine studies.

R/r 911

 

[AJ Hidell]

Why exactly was the patient RSI'd?

 

[Flight-LP]

Why exactly was the patient RSI'd?

im wondering the same thing...........

my other question is why narcan was given after the pt was RSI'D?

 

[AJ Hidell]

Makes me wonder if someone didn't overmedicate with the RSI.

 

[Aidey]

Flight LP it sounds like the medic continued to give narcan because the patient was still hypotensive (thats just a guess from the first post).

As for the RSI, there aren't enough details here, but if someone has taken a benzo OD, and you don't have flumazenil on your ambulance, and the patient can't maintain their own airway, then RSI could be indicated depending on the local protocol. (I know in mine it would be and option).

 

[JPINFV]

If the lowpertension was d/t narcos, then the naloxone will reverse them. It is important to say that narcan is NOT a vasopressor, nor does it reverse alprazolam. For that you'll need flumazenil, also not a pressor.

lowpertension?

 

[daedalus]

Why exactly was the patient RSI'd?

I am asking the same question. Plus, once the patient's tubed, if you can stabilize the BP, why even give the Narcan?

 

[AJ Hidell]

I am asking the same question. Plus, once the patient's tubed, if you can stabilize the BP, why even give the Narcan?

Seriously. The last thing I want is for my tubed patient to become un-gorked in the field. But then again, I wouldn't have tubed this one in the first place.

 

[Flight-LP]

Flight LP it sounds like the medic continued to give narcan because the patient was still hypotensive (thats just a guess from the first post).

As for the RSI, there aren't enough details here, but if someone has taken a benzo OD, and you don't have flumazenil on your ambulance, and the patient can't maintain their own airway, then RSI could be indicated depending on the local protocol. (I know in mine it would be and option).

Hate to write and run as I only have a couple of minutes, but a few points that need to be addressed..............

1. If a pt. is truly a GCS of 3, then why the need for paralytics??? Granted, the condition or neuro response can change, but if they are truly unresponsive without a gag, then just drop the ET tube. Risk vs. benefit.

2. Narcan after intubation, especially with RSI, is a horribly ignorant (or stupid if you already know better) idea. You sedate, paralyze, and provide analgesia for a reason. That reason is not to reverse it. Plus, analgesia is a must with RSI. Lets look at our options, usually Morphine or Fentanyl. What is Narcan going to do to either them?????? Hmmmmm...

3. Leave Romazicon out of this conversation. The only reason we in the pre-hospital environment should be giving this antagonist is for our own screw-ups, i.e. a Paramedic induced benzodiazepine OD. Too many people run and start slamming Romazicon with no clue as to the potential complications. Most benzos have a relatively short half life. Romazicon is overused and rarely truly needed.

Sorry, but your medic needs to revisit some basic airway education, along some recent literature and research. Hopefully, everyone learns a little something out of this.

Take care, be safe!

 

[firemedic31075]

Why exactly was the patient RSI'd?

After the my partner gave 2mg of narcan IM the pt. began gagging on the OPA and continued to have a gag reflex when we go to the back of the unit so the decision was made to RSI rather than attempt to just tube her and risk vomiting and aspiration.

I ask why was the Narcan given IM as appearantly you were able to RSI?

It was given initially on scene before we had an IV.

once the patient's tubed, if you can stabilize the BP, why even give the Narcan?

That's what I was thinking..our protocol is Etomidate and Succs for RSI (we don't use any opiates in RSI other than a trauma situation) and versed and Vecc for longer duration, which narcan wouldn't affect, so I guess there was no harm in giving it. I myself would not have given it had I been the lead medic. I would have tried other measures to correct the b/p

Seriously. The last thing I want is for my tubed patient to become un-gorked in the field. But then again, I wouldn't have tubed this one in the first place

Why would you not tube this pt.?? She is completely unresponsive.


Thanks for all the feedback so far.

 

[maxwell]

Yeah yeah yeah, lowpertension = hypotension.

I'm gonna give an amen to NOT giving naloxone to an intubated patient. They can do it in the ED as a diagnostic if they really want to (when they can *quickly* snow 'em again with the milk of amnesia). I am a fan of my intubated patients not moving.

I'm not sure I would have intubated, either, frankly. But, I wasn't there. Hell where I'm from we make those types walk to the rig h34r:.

 

[AJ Hidell]

Why would you not tube this pt.?? She is completely unresponsive.

If she is gagging on an OPA, she is not completely unresponsive. If she is gagging on an OPA, she doesn't need an OPA. If she doesn't need an OPA, then she darn sure doesn't need an ETT. Not every unconscious person needs an ET tube. An ET tube is not simply a lazy medic's way of getting out of basic airway control. I just don't think you'd find too many medical control physicians who would say this was justified PAI.

That is just extremely poor planning and decision making to hit someone with naloxone and then RSI them.