Narcan or not

[Fish]

I'll posit another scenario: 65 year old female, history of hypertension, hypercholestremia, AF, osteoarthritis. Found unresponsive in bed, HR 50, BP 90/50, resp rate 6, pupils pinpoint, GCS 3 and peripherally cyanosed. Do you give narcan? QUOTE]

Other than your reduced ability to manage pain w/opiate analgesia, what would be the down side? I had a similar case about a year ago, with added hx of depression, no opiates in residence. A trial of Narcan reversed the event, pt woke and admitted to taking a large amount of Oxycodone.

The other way that call would have played would have been an un needed intubation, CT scan and ICU admit, although with the ability to add Fentanyl or your opiate of choice to round out her analgesia/sedation.

Not saying the other course of action would be "wrong" per se, it's just a different approach.

Although us American medics are a pack of retards, the physician level of providers for the most part are not. FWIW

Haha

 

[DrParasite]

Sort of related, what are the side affects of administering Narcan on a person who is not overdosing on an opiate?

 

[Dwindlin]

Sort of related, what are the side affects of administering Narcan on a person who is not overdosing on an opiate?

If the patient is opiate dependent it can cause an acute withdrawal (which is uncomfortable but not lethal).

It has been shown to cause an acute sympathetic reaction (including cases of v-fib/v-tach) but these instances have only been in post-op patients who already had a history of cardiac disease (so was it the narcan?)

OUtside of this not much (nausea is the most common).

I must say I disagree with Smash on this one, there is very little harm in giving the presented patient Narcan, as the analgesia post-induction argument is moot in my opinion. Narcan is a competitive antagonist, meaning it can be overcome with more narcotics. In the setting of post-intubation sedation morphine and fentanyl can both be ran at 150/hr (mg and mcg respectively). This is WELL more than enough to overcome the Narcan and provide analgesia.

 

[Fish]

If the patient is opiate dependent it can cause an acute withdrawal (which is uncomfortable but not lethal).

It has been shown to cause an acute sympathetic reaction (including cases of v-fib/v-tach) but these instances have only been in post-op patients who already had a history of cardiac disease (so was it the narcan?)

OUtside of this not much (nausea is the most common).

These are side affects to someone who HAS had an opiate overdose, Parasite was askin what the side affects are if you give it to someone who has not taken any opiates at all

I must say I disagree with Smash on this one, there is very little harm in giving the presented patient Narcan, as the analgesia post-induction argument is moot in my opinion. Narcan is a competitive antagonist, meaning it can be overcome with more narcotics. In the setting of post-intubation sedation morphine and fentanyl can both be ran at 150/hr (mg and mcg respectively). This is WELL more than enough to overcome the Narcan and provide analgesia.

Agreed, but what I am failing to see here is. Why can we still not achieve sedation when intubating even if we have given Narcan? Do other systems not use IV Versed as a sedative performing an RSI? If dosed properly with a Benzo then a narcotic is not needed, am I wrong?

 

[DrParasite]

Exactly Fish. Lets say we are bored at the station one night, someone starts an IV on me, and administers 2 mg of Narcan. No drugs in my system what will happen to me? are there any side effects? (and no, we don't start IVs on coworkers and give narcan just because we are bored).

Following that line of thinking, if I find a man unresponsive on the ground, with pinpoint pupils, and he has no opiates in his system (but I don't know this at the present time), and I give narcan, what will happen? will anything happen? will anything detrimental happen? or will it do absolutely nothing to the patient?

so if it won't hurt the patient, and might (snowballs chance here) help the patient, what is the problem with giving it?

 

[Smash]

I must say I disagree with Smash on this one, there is very little harm in giving the presented patient Narcan, as the analgesia post-induction argument is moot in my opinion. Narcan is a competitive antagonist, meaning it can be overcome with more narcotics. In the setting of post-intubation sedation morphine and fentanyl can both be ran at 150/hr (mg and mcg respectively). This is WELL more than enough to overcome the Narcan and provide analgesia.

You certainly "could" run heroic amounts of morphine or fentanyl, but I have a couple of issues with that.
One: if your transport time is longer than a few minutes, how many people actually carry 20 odd ampoules of morph or fentanyl? My transport times are typically 30-60 minutes, so it quickly becomes logistically problematic to take this approach. So why not save yourself the issue?
Two: The "can't hurt" mentality typically leads to things that do indeed hurt. Like O2 for everyone for example. But more importantly it completely misses the point of actually examining and treating the patient. Real life is not like Princeton-Plainsboro. We can't just start giving crap to rule out things that have next to no likelihood of being present. (And it's never sarcoidosis)

If someone calls an ambulance because they feel generally weak and crappy, you don't go giving calcium gluconate just in case it's hyperkalemia. We don't automatically give someone who is sweaty dextrose just in case they are having a hypo. We assess them, we gather all the info we can, and when we have a reasonable working diagnosis, we go ahead and treat with a reasonable expectation that we are on the right track. At least, this is how medicine works in my world.

Sure, the risks of naloxone may be less than some other medications, but it is still symptomatic of lazy, poorly educated, ineffective and potentially dangerous practice. The patient in the OP didn't need random drugs squirted into him given the manifest issues that this could cause, he needed some airway management, some ventilation (by whatever means one considers most appropriate, not necessarily intubation) and some transport.
The OP achieved this, even though I think the airway management was sub-optimal.

Agreed, but what I am failing to see here is. Why can we still not achieve sedation when intubating even if we have given Narcan? Do other systems not use IV Versed as a sedative performing an RSI? If dosed properly with a Benzo then a narcotic is not needed, am I wrong?

In a word, yes. Analgesia is a vital, non-negotiable part of intubation and post intubation care. The sedation is the icing on the cake, the added bonus to make the patient a little happier. Fentanyl based anesthesia, primarily using large doses of fentanyl (or remifentanil, sufentanil) and little else (a small concentration of a volatile, or maybe a little midazolam or etomidate) is a common sight in OR, particularly in cardiac anesthesia.
Also, I'm curious whether you will address any of the other points I made.

 

[Fish]

You certainly "could" run heroic amounts of morphine or fentanyl, but I have a couple of issues with that.
One: if your transport time is longer than a few minutes, how many people actually carry 20 odd ampoules of morph or fentanyl? My transport times are typically 30-60 minutes, so it quickly becomes logistically problematic to take this approach. So why not save yourself the issue?
Two: The "can't hurt" mentality typically leads to things that do indeed hurt. Like O2 for everyone for example. But more importantly it completely misses the point of actually examining and treating the patient. Real life is not like Princeton-Plainsboro. We can't just start giving crap to rule out things that have next to no likelihood of being present. (And it's never sarcoidosis)

If someone calls an ambulance because they feel generally weak and crappy, you don't go giving calcium gluconate just in case it's hyperkalemia. We don't automatically give someone who is sweaty dextrose just in case they are having a hypo. We assess them, we gather all the info we can, and when we have a reasonable working diagnosis, we go ahead and treat with a reasonable expectation that we are on the right track. At least, this is how medicine works in my world.

Sure, the risks of naloxone may be less than some other medications, but it is still symptomatic of lazy, poorly educated, ineffective and potentially dangerous practice. The patient in the OP didn't need random drugs squirted into him given the manifest issues that this could cause, he needed some airway management, some ventilation (by whatever means one considers most appropriate, not necessarily intubation) and some transport.
The OP achieved this, even though I think the airway management was sub-optimal.



In a word, yes. Analgesia is a vital, non-negotiable part of intubation and post intubation care. The sedation is the icing on the cake, the added bonus to make the patient a little happier. Fentanyl based anesthesia, primarily using large doses of fentanyl (or remifentanil, sufentanil) and little else (a small concentration of a volatile, or maybe a little midazolam or etomidate) is a common sight in OR, particularly in cardiac anesthesia.
Also, I'm curious whether you will address any of the other points I made.

I will try, you POSTED A LOT! And when I attempted to respond twice yesterday we got toned out for calls so I gave up. And right now is study time for a class.

 

[systemet]

Right, the history and patient presentation screams Narcan.

I respect your opinion, but disagree with you, the history and presentation scream he overdosed on seroquel and klonopin again.

I would also be hesitant to give narcan in this situation, and in my previous job was encouraged to just intubate mixed overdoses even if there was a strong possibility that an opiate was involved, unless I was certain that it was an isolate opiate overdose.

My experience on this forum and others, has been that providers that work in areas where there is a greater amount of illict IV opiate/opiod use are more likely to give narcan in borderline situations, and are more likely to be supported by their local medical control. Those of use who work in areas where opiate / opiod use is less common, tend to be more conservative.

 

[Fish]

My experience on this forum and others, has been that providers that work in areas where there is a greater amount of illict IV opiate/opiod use are more likely to give narcan in borderline situations, and are more likely to be supported by their local medical control. Those of use who work in areas where opiate / opiod use is less common, tend to be more conservative.

Very good point, were I came from it was a common drug. Sometimes going out of service so that we can restock because the 4 preloads that we carried on the ambulance got used. Also, the Docs were more Liberal with it.

 

[systemet]

Very good point, were I came from it was a common drug. Sometimes going out of service so that we can restock because the 4 preloads that we carried on the ambulance got used. Also, the Docs were more Liberal with it.

Maybe you can give some input on another question that's come up then?

A lot of people seem to have the impression that an absence of improved respirations or level of consciousness with a single 0.4mg dose of narcan IV, is a rule-out for opiate / opiod intoxication. This is the idea of "diagnostic narcan".

My limited experience has been that even what I'd consider quite large doses of narcan seem to be ineffective against some opiates / opiods, for example methadone, or darvon. It used to be that some years back when narcan protocols were a little more aggressive, and often 2mg was a standard IV dose, and 4mg was being given IM, that we still used to see patients that would require several doses.

* What's your experience been? Because I find myself compelled to point out to people that a lack of response to 0.4mg of narcan is pretty meaningless (at least in my opinion).

I realise what I'm asking for is anecdotal experiences, which most of us don't value too highly, but I'm just interested at to whether you, or anyone else agrees or disagrees with this.

 

[Smash]

I will try, you POSTED A LOT! And when I attempted to respond twice yesterday we got toned out for calls so I gave up. And right now is study time for a class.

Fair enough I do tend to rattle on a bit.

 

[Fish]

Maybe you can give some input on another question that's come up then?

A lot of people seem to have the impression that an absence of improved respirations or level of consciousness with a single 0.4mg dose of narcan IV, is a rule-out for opiate / opiod intoxication. This is the idea of "diagnostic narcan".

My limited experience has been that even what I'd consider quite large doses of narcan seem to be ineffective against some opiates / opiods, for example methadone, or darvon. It used to be that some years back when narcan protocols were a little more aggressive, and often 2mg was a standard IV dose, and 4mg was being given IM, that we still used to see patients that would require several doses.

* What's your experience been? Because I find myself compelled to point out to people that a lack of response to 0.4mg of narcan is pretty meaningless (at least in my opinion).

I realise what I'm asking for is anecdotal experiences, which most of us don't value too highly, but I'm just interested at to whether you, or anyone else agrees or disagrees with this.

I would agree that it is not, 0.4mg I have seen this small of an amount work on pain management patients and heroin sometimes. But on the flip side I have had to give 4mg for it to work. I don't see 0.4mg as being "diagnostic"

 

[Fish]

Fair enough I do tend to rattle on a bit.

As a side note, I would be stoked if that picture in your avatar is really you! I dig the Fro!

 

[systemet]

As a side note, I would be stoked if that picture in your avatar is really you! I dig the Fro!

Seconded.

 

[Dwindlin]

You certainly "could" run heroic amounts of morphine or fentanyl, but I have a couple of issues with that.
One: if your transport time is longer than a few minutes, how many people actually carry 20 odd ampoules of morph or fentanyl? My transport times are typically 30-60 minutes, so it quickly becomes logistically problematic to take this approach. So why not save yourself the issue?
Two: The "can't hurt" mentality typically leads to things that do indeed hurt. Like O2 for everyone for example. But more importantly it completely misses the point of actually examining and treating the patient. Real life is not like Princeton-Plainsboro. We can't just start giving crap to rule out things that have next to no likelihood of being present. (And it's never sarcoidosis)

If someone calls an ambulance because they feel generally weak and crappy, you don't go giving calcium gluconate just in case it's hyperkalemia. We don't automatically give someone who is sweaty dextrose just in case they are having a hypo. We assess them, we gather all the info we can, and when we have a reasonable working diagnosis, we go ahead and treat with a reasonable expectation that we are on the right track. At least, this is how medicine works in my world.

Sure, the risks of naloxone may be less than some other medications, but it is still symptomatic of lazy, poorly educated, ineffective and potentially dangerous practice. The patient in the OP didn't need random drugs squirted into him given the manifest issues that this could cause, he needed some airway management, some ventilation (by whatever means one considers most appropriate, not necessarily intubation) and some transport.
The OP achieved this, even though I think the airway management was sub-optimal.

I wouldn't suggest running these amounts pre-hospital. In this area it is completely acceptable to maintain adequate sedation post-intubation and allow the E.D. to start analgesia (and frankly we don't have protocols for it).

Again, in this area an overdose is rarely one drug, and rarely am I told everything they ingested. I can not count the number of times I have been in this exact situation (absolutely no objective evidence outside of exam) and a couple mg of Narcan brought them around enough to avoid a tube. The benefit in this case FAR outweighs the risks in my opinion (and the opinion of my medical director as he would be very angry if I brought in an overdose, whom I tubed w/o at least a trial of Narcan).

I don't expect you to ever agree with me, and that's fine, that is one of the greatest benefits of public forums. But I would hope you realize the bolded statement is a gross over generalization. Maybe you can trust your patients and their family where you work, here I rarely can, so yes I play the odds and believe me it has worked out in my favor FAR more than the opposite.

 

[Remeber343]

As this has been resurrected: this call also would have generated a review in my system, but only if I gave a drug that is not indicated for a problem that doesn't exist. That is unlikely to happen though, because I treat what I can reasonably deduce to be wrong with the patient. I don't treat pinpoint pupils. Maybe that is just me, but then I was educated to practice medicine.

They aren't saying they are treating pinpoint pupils, they are treating the whole picture. As previously states, hx of poss. OD's, and the fact that he did take some meds, and as others have said, he may have OD on opioids, whose to say he didn't? Try before you pry man, no need to go shoving a tube down someones throat if it could have been fixed with something as simple as narcan. I'm not saying dont prepare for intubation, have everything ready in case its needed, but to jump straight to that w/o considering anything is kind of scary imo. I much rather try to fix the underlying problem then having to have this pt intubated and have to go through all the issuies that might occur with that.

 

[Fish]

They aren't saying they are treating pinpoint pupils, they are treating the whole picture. As previously states, hx of poss. OD's, and the fact that he did take some meds, and as others have said, he may have OD on opioids, whose to say he didn't? Try before you pry man, no need to go shoving a tube down someones throat if it could have been fixed with something as simple as narcan. I'm not saying dont prepare for intubation, have everything ready in case its needed, but to jump straight to that w/o considering anything is kind of scary imo. I much rather try to fix the underlying problem then having to have this pt intubated and have to go through all the issuies that might occur with that.

Agreed

 

[emspgh]

I don't see any indications to give naloxone. Sure, he has miosis and respiratory depression, but there are more things than just opioids that will cause this. I realise that the brother turned up after you managed his airway, but that is just bad luck, you can only act on the information that you find at the time, and you found nothing to make you suspect opioids were part of the problem."

When a pt has respiratory depression, and miosis, especially with a history of some kind of OD (be it with benzos, but the risk still applies that maybe he switched to narcs), then by all means, narcan the patient. If he wakes up, and you can avoid intubation, then perfect. Yes, it can be great in the field, but it increases morbidity and mortality in the long run. Intubation should not be the first step in a patient who can breathe, or is apneic when medications like narcan are available. There's no harm in bagging after giving narcan to see if it works.

I know the post mentioned that the bystanders couldn't tell if the patient was breathing or not, but does anyone know if the patient actually was?

 

[chaz90]

I don't see any indications to give naloxone. Sure, he has miosis and respiratory depression, but there are more things than just opioids that will cause this. I realise that the brother turned up after you managed his airway, but that is just bad luck, you can only act on the information that you find at the time, and you found nothing to make you suspect opioids were part of the problem."

When a pt has respiratory depression, and miosis, especially with a history of some kind of OD (be it with benzos, but the risk still applies that maybe he switched to narcs), then by all means, narcan the patient. If he wakes up, and you can avoid intubation, then perfect. Yes, it can be great in the field, but it increases morbidity and mortality in the long run. Intubation should not be the first step in a patient who can breathe, or is apneic when medications like narcan are available. There's no harm in bagging after giving narcan to see if it works.

I know the post mentioned that the bystanders couldn't tell if the patient was breathing or not, but does anyone know if the patient actually was?

Necro post man. I don't think anyone is actively reading this and remembering the 2+ year old call.

 

[emspgh]

Necro post man. I don't think anyone is actively reading this and remembering the 2+ year old call.

Okay, I just clicked and read it. No harm, no foul.....