Routine Narcan Use

[medicsb]

Naloxone has one indication, and one indication only: respiratory depression which is suspected to have been caused by opioids.

Narcan should not be used as part of a "coma cocktail", or just because someone is unresponsive and we don't know why. ...

Now that said, given the severity of the opioid crisis that we are experiencing, I don't think there is anything wrong with having a high index of suspicion for opioid overdose in a comatose or very lethargic patient, and a fairly low threshold for using naloxone for that reason.

But you still need to have respiratory depression, and I think you still need to have some reason to think that the cause of the respiratory depression is opioids, in order to justify its use.

I had a rather interesting case tonight. Man in his 60s is witnessed by family to go unresponsive. CPR by FFs, found to have a pulse by medics (no epi or shocks). Man is older, no possible cause of unconsciousness reported by family. Glc ok. Other than some apparent agonal resps, vitals are stable. Medic nasally intubates successfully and transport. Pt. begin waking in resusc bay, following commands, etc. Vent parameter are great and I extubate before EMS is out the door. Man admits to snorting heroin. Now, I don't typically give narcan to every unresponsive person, but in certain cases it is worth a try. One of those potential cases would be if you are about to intubate. Using a small dose or 2 (0.2-0.4mg per dose) might be worthwhile. However, I would only advocate that in cases where there isn't other findings suggesting another cause (e.g. signs of trauma, a blown pupil, posturing, etc.). Anyhow, that was live and learn case for the medic and no harm was done. (Family later 'remembered' that he had a heroin problem.)

 

[Handsome Robb]

I believe our service is moving forward towards some very exciting progressive protocols.

Our current protocol came about from first responders utilizing narcan prior to EMS arrival on suspected overdoses. This has become common practice in several states around here that have law enforcement and fire department carrying narcan. We get on scene and the patient is now alert and oriented and obviously does not want to go to the hospital the majority of the time. We stay on scene with the patient for 30 minutes, do standard refusal paperwork, vitals. We monitor for signs of increased lethargy or respiratory depression or onset of altered status or diminished LOC during the 30 minutes. Currently we can write the refusal and get signatures, and we have the option to contact our med control for a 2mg narcan booster at the end of the two minutes if the patient is competent to refuse however we have concerns about them going back into diminished LOC and respiratory depression from the narcotics at a later point. We are just starting to trial this and I imagine the protocol will expand and begin to be utilized more often. We have the support of the hospitals who don't want half a dozen of these patients every night taking up 6 hallway beds only to be discharged 8 hours into the night when they wake up and get a ride.

Generally speaking we aren't waking these people up (as far as EMS giving the narcan) without someone on scene who can give us a good idea that its a simple narcotics overdose without suicidal intentions. Usually those same people are the ones that say the patient was just taking some pills and having a good night and they will be with them the rest of the night and make sure they are okay. We make sure to get full information of the party that insists they will take care of them and call back if needed.

Anyways, in the region I am in my system probably responds to a dozen overdoses a day, probably 1 or 2 getting narcan. We have very few ill effects with narcan and it is usually just some nausea.


If anyone else is currently doing any form of "treat and release" program with narcotics overdoses I would love to get your view on it

@STXmedic and his service have been doing it for a while I believe.


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[STXmedic]

@STXmedic and his service have been doing it for a while I believe.


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You would be correct, sir. We've been doing this for the last 8-10 years. We wake them up with 2-4mg (if it takes more than 4, we'll typically transport). Then assuming they don't want to go, we have them sign, give them 2mg IM for the road, then let them be on their way.

There's no specific amount of time that we have to wait on scene- as soon as they're oriented and no longer lethargic we can let them go. We also don't have to contact anybody for this (Med Control or Med Dir). This is assuming no other concurrent issues, just a straight heroin OD. My service sees these 5 times per day or so. @Rialaigh

 

[EpiEMS]

You would be correct, sir. We've been doing this for the last 8-10 years. We wake them up with 2-4mg (if it takes more than 4, we'll typically transport). Then assuming they don't want to go, we have them sign, give them 2mg IM for the road, then let them be on their way.

I was told (anecdotally) that this was common practice in New York during the 1980s and early 1990s - naloxone via IVP then an IM dose...but, again (anecdotally), this was against protocol.