Narcan 2 mg vs 0.4 mg - which do you give?

[Angry Birds]

I just usually say f it, give 2. Go big or go home. You?

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[gro2001]

In almost all situations I start with an even smaller dose: 0.04 mg, but I give repeat doses quickly (Q 30 seconds) until the desired effect is reached. Desired effect being breathing at a rate of 8-12 but not necessarily awake. Usually it takes 2-3 doses of 0.04 mg to reach this desired effect. The last thing I want is them waking up and bolting out of the ER and the collapsing again a few blocks down as the naloxone has worn when but the methadone hasn't. The one exception to this practice is when they come in blue/perimortem from a suspected opioid ingestion an unknown time ago, in which case I give larger doses and don't stop until I've given at least 4-10 mg.

 

[Angry Birds]

In almost all situations I start with an even smaller dose: 0.04 mg, but I give repeat doses quickly (Q 30 seconds) until the desired effect is reached. Desired effect being breathing at a rate of 8-12 but not necessarily awake. Usually it takes 2-3 doses of 0.04 mg to reach this desired effect. The last thing I want is them waking up and bolting out of the ER and the collapsing again a few blocks down as the naloxone has worn when but the methadone hasn't. The one exception to this practice is when they come in blue/perimortem from a suspected opioid ingestion an unknown time ago, in which case I give larger doses and don't stop until I've given at least 4-10 mg.

See, I don't get it. Practically I only really give Narcan if the patient is on deaths doorbed. Also, I want to see if the Narcan worked and so 2 mg makes sense.

I've never had a patient become violent after Narcan but this may be from lack of experience. If they did dart out the ER, then another life saved and have a good day. Shrug.

 

[Daiphon]

See, I don't get it. Practically I only really give Narcan if the patient is on deaths doorbed. Also, I want to see if the Narcan worked and so 2 mg makes sense.

I've never had a patient become violent after Narcan but this may be from lack of experience. If they did dart out the ER, then another life saved and have a good day. Shrug.

If breathing:
2mg + 3mL respiratory saline as a neb.
When they're awake enough, they rip off the mask & cuss me out. Self-titrating, avoids the mess.

If not breathing + normal color:
4/4/4
Awake = order zofran
Not awake = tube

If not breathing + blue:
Tube. I don't bother with narcan b/c if blue, then is gonna need a bunch of tests to look for EOD, and easier to do if ventilated.

(e.g. they've already taken the trouble to induce, I may as well take advantage of it).

-d

Semper Brunneis Pallium

 

[WilcoWorld]

I usually start with 0.4mg, but I might have to try Diaphon's approach at the next opportunity.

 

[engineeredout]

Blue = Two

 

[gro2001]

See, I don't get it. Practically I only really give Narcan if the patient is on deaths doorbed. Also, I want to see if the Narcan worked and so 2 mg makes sense.

I've never had a patient become violent after Narcan but this may be from lack of experience. If they did dart out the ER, then another life saved and have a good day. Shrug.

Well, it's not like I have a ton of experience either. I am mostly going off what Goldfrank says and what I've picked up from my tox attendings in residency. I was similarly skeptical of this approach at first too, but having tried it am now a fan.

In terms of rationale: there's different levels of dying. There is the overdose that's breathing at 4 times/minute but has a sat in the low 90s... I can't just leave him like that, but he can wait 1-2 minutes over which I give 3-4 pushes of the 0.04 mg. I will titrate till he is breathing at a decent rate, maybe arousable with sternal rub, but falling back asleep and breathing at a rate of 10-12 when left to his own devices. Usually I can achieve this with only 2-4 pushes of 0.04 or so. I want them breathing but not awake.

And there is one that is brought in blue, with sats in the 60s, not breathing at all... that one can't wait. Him I give 0.4 mg or more and keep going.

In terms of them darting out of the ER: if they only did heroin or something equally short lasting, then sure that's probably fine. The opioid will likely wear off (or at least will be past peak effect) around the same time as the narcan wears off. But if they OD'ed on something like methadone, the naloxone will wear off in 30 minutes but the the methadone will keep going for hours. If they collapse again and something bad happens, then its on you.

 

[UKEMdoc]

I usually give them an IM bonus before the IV(400mcg). If they're blue then I bag them for a couple of minutes.

Advantage of IM is the patient is a couple of hours away when the naloxone wears off.

 

[The White Coat Investor]

Both. First 0.2-0.4mg to see if it works, then 2 mg to be sure. If the medics already gave some without effect, then 2 mg. If 0.2 is plenty, then I stop there. The nurses thank me for that approach.

 

[RPedigo]

If they are breathing, I typically do 0.04 mg as well (take the 0.4 mg dose which is 1 mL at standard concentration and draw it up in a 10 mL saline flush that I squired 1 mL out of, so it's now 0.4 mg in 10 mL or 0.04 mg/mL) and just give 1 mL at a time while preoxygenating them for intubation in case it fails. The reason I did this is once I got a patient who was reportedly GCS 1-1-1, suspected heroin overdose, and was given 2 mg of naloxone upon arrival to the ED and then was agitated, violent, breaking things, and was very difficult to manage the patient. Now I just titrate to breathing and being able to be easily awoken, but not conversant.

 

[shookwell]

I also do 0.04 mg, titrate to adequate respiration, leave them obtunded. I've tried the nebulizer thing and it only works well on the people who are breathing well enough to not really need narcan at all. Those I just let them sleep it off.

Occasionally I'll give a higher dose if there is diagnostic uncertainty and I am on the fence about whether they need bloodwork/head CT/etc. But most people will start breathing better somewhere between 0.04-0.4 mg and then you don't have to do anything else to them.

 

[Janders]

Different doses for different situations.

Frankly I rarely get the blue-CPR-in-progress-apneic-peri-arrest-heroin-OD patients anymore due to the penetration of nasal narcan in the community, police force, and EMS/FIRE.
That said if we're to the point of cardiovascular collapse they get 2mg IV or nasal and then another couple doses if it didn't work.

More commonly, we have the bluish-barely-breathing-but-with-a-good-pulse patient. With these I'll do something in the 0.1-0.4mg range IV while we bag them up, up titrating to effect.

Then you have the high-as-a-kite patients, with a RR of 6 who are snoring and have a room air sat of 85%. These get little tiny doses 0.04mg, escalating as needed, to get them safely breathing.

We also have the patients who are altered, polypharmacy patients with unclear histories and sometimes we'll try narcan diagnostically. I typically do that a 0.4mg IV. Sometimes I'll try 2mg IV after if no response.

The issues I have with just slamming 2mg IV into everyone-->
(1) I've seen some nasty post-narcan pulmonary edema with rapid respiratory collapse. Sure you can likely crash intubate them and positive-pressure your way through it, but I'd rather avoid that if possible.
(2) I've seen some nasty post-narcan violence, delirium, and nurse-punching. While cutting off their high might "teach them a lesson", it might also involve me and 5 other staff members playing tackle-the-violent-guy and looking for leather restraints. Certainly we can manage this, but I'd rather avoid that if possible.

If you are going to push 2mg IV, I would suggest preemptively placing solid 4-point restraints and positioning yourself out of punching/biting/spitting range

 

[gro2001]

Also, I'd like to point out that the lowest effective dose of naloxone isn't even 0.04 mg. It's having the vial in your hand and whispering 'narcan...' next to the patient. Sometime's that's sufficient.

 

[Apollyon]

See, I don't get it. Practically I only really give Narcan if the patient is on deaths doorbed. Also, I want to see if the Narcan worked and so 2 mg makes sense.

I've never had a patient become violent after Narcan but this may be from lack of experience. If they did dart out the ER, then another life saved and have a good day. Shrug.

If you think that ammonia is battery, pounding in 2mg of Narcan has a high probability of being just as violent.

 

[GonnaBeADoc2222]

I agree with all of the above. I do like the dilution of 0.4 mg into little 0.04 mg/ml squirts that someone mentioned above. One of my tox attendings taught me this. I would add that in my region (northeast USA) we have seen a rash of fentanyl contaminated heroin and even cocaine which has resulted in more than a handful of fatalities. In these cases, much larger than expected doses of narcan may be required, sometimes up to 10 mg.

 

[Angry Birds]

So, I guess it comes down to my lack of experience. I just haven't yet had anyone get violent after Narcan. Pissed? Yes. But not punching people.

And I don't care if they run out. It's not on me if they do that. I disagree with whoever said that.

 

[canigetawhatwhat]

0.4 if bradypnic.
1 if unresponsive
2 if apneic

If unresponsive. 1 then 2 then tube
If apneic 2 then tube

-hov

 

[txterp98]

"Why am I about to intubate?" --> 2mg

"Why is this person obtunded?" --> 0.4mg

 

[gro2001]

And I don't care if they run out. It's not on me if they do that. I disagree with whoever said that.

I see where you are coming from, and on an emotional level I agree with you. Maybe its a philosophical decision. But its like letting someone intoxicated flee your ER. You know the reversal agent only lasts 30 mins or so, and if they took something much longer lasting then they could go right back to that level of intoxication as soon as your reversal agent wears off, which you know based on its pharmacology will happen sooner. Knowing that, I don't think its right to let them run out. Unless you think it wasn't right to bring them in in the first place, and whatever state of intoxication they were in before wasn't dangerous... but then you wouldn't be giving the narcan, would you?

 

[Angry Birds]

I see where you are coming from, and on an emotional level I agree with you. Maybe its a philosophical decision. But its like letting someone intoxicated flee your ER. You know the reversal agent only lasts 30 mins or so, and if they took something much longer lasting then they could go right back to that level of intoxication as soon as your reversal agent wears off, which you know based on its pharmacology will happen sooner. Knowing that, I don't think its right to let them run out. Unless you think it wasn't right to bring them in in the first place, and whatever state of intoxication they were in before wasn't dangerous... but then you wouldn't be giving the narcan, would you?

Thanks for the interesting and cordial conversation. I don't think this is an easy decision either way, so there is of course a counter-argument to what I'm saying. However, I think my view is stronger and here is why:

The physician has to balance two principles: autonomy and beneficence. In our society we rightfully place a high emphasis on autonomy, such that it would be kidnapping to keep a patient in the ER against their consent.

The idea that intoxicated patients have zero autonomy and no consent is no longer acceptable, because many people live their whole lives inebriated. Therefore, most states/courts have ruled that an ER is not liable if an inebriated patient storms out of the ER and is hit by a truck because of being drunk. It's not just that the ER is discharged of its responsibility, but that one cannot curtail the civil liberties of every drunk.

I've had plenty of opiate overdose patients leave the ER after getting Narcan. They understand the risks of opiate abuse and continue to abuse despite that. They also accept that the Narcan will wear off and in fact want that. In such a case it is not acceptable to hold them against their will.

One could certainly use a lower dose of Narcan to circumvent this situation, and that's arguable. But what I am disagreeing with is the idea that I'm liable if the Narcan'd druggie leaves the ER. Not only am I not liable but I cannot justifiably curtail that patient's civil liberties. In this scenario I gave the patient the Narcan dose to save their life when they had no ability to consent.

Again, one could justify a lower dose to circumvent the dilemma, and that's fine. I guess another issue I have with this approach is that I feel uneasy having an altered patient with low respiratory rate in my ER, especially since their respiratory drive and airway is an issue. That's why I'm slamming 2.


Anyways, I'm not a tox trained guy, and this is just my own (limited) experience. I feel that if and when I have a Narcan'd patient punch a nurse then I'll change my practice.

 

[WilcoWorld]

I don't know if I'm getting jaded by too many years in "county" type ED's, or if I'm simply becoming more pragmatic in the light of experience. Last week I allowed a frequent flyer to leave AMA and, when shortly thereafter the EtOH that the resident ordered came back >300, the resident just about panicked. I wasn't too worried and this was vindicated last night when this same patient looked his usual self as he checked in at about 8pm.

Here is how my interaction with intoxicated patients typically goes nowadays:

Me: "I understand that you want to leave. Do you want to hurt yourself or anyone else?"
Patient gives an evasive answer and criticizes the healthcare system/hospital, impugnes my ethics and medical credentials, then makes a comment about my looks.
Me: "Do you want to hurt yourself or anyone else?"
Patient: "No."
Me, as I clear a path between the patient and the exit: "We're here 24/7, come back if you need us."

Then I document something in the chart about how a) Based on the information available I didn't have grounds to hold the patient against his or her will, thereby depriving the patient of autonomy and b) how using force or medications to detain a person against his or her will is probably higher risk than allowing a non-suicidal/non-homicidal person who is walking and talking to leave the ED.

 

[Apollyon]

Dr Wilco, if you ARE a doctor, you suck, and you look funny, but not "funny haha". You suck! And I am not a great orator! But I'm not paying my bill!

Which is about par for the course.

 

[gro2001]

I don't know if I'm getting jaded by too many years in "county" type ED's, or if I'm simply becoming more pragmatic in the light of experience. Last week I allowed a frequent flyer to leave AMA and, when shortly thereafter the EtOH that the resident ordered came back >300 the resident just about panicked. I wast too worried and this was vindicated last night when this same patient looked his usual self as he checked in at about 8pm.

Here is how my interaction with intoxicated patients typically goes nowadays:

Me: "I understand that you want to leave. Do you want to hurt yourself or anyone else?"
Patient gives an evasive answer and criticizes the healthcare system/hospital, impugnes my ethics and medical credentials, then makes a comment about my looks.
Me: "Do you want to hurt yourself or anyone else?"
Patient: "No."
Me, as I clear a path between the patient and the exit: "We're here 24/7, come back if you need us."

Then I document something in the chart about how a) Based on the information available I didn't have grounds to hold the patient against his or her will, thereby depriving the patient of autonomy and b) how using force or medications to detain a person against his or her will is probably higher risk than allowing a non-suicidal/non-homicidal person who is walking and talking to leave the ED.

That's more or less my approach as well.

I think there is no hard and fast rule in terms of what we are liable for or not, except perhaps the one rule that the lawyers can always make it your fault. Its probably both legally wrong to hold them against their will and its probably going to be a successful lawsuit if you let them go and they get hit by a bus. What's the bigger risk depends on what kind of patient you have. The semi homeless habitual drunk is just not going to go find a lawyer to sue you for unlawful detention (or whatever its called), but his family might suddenly come out of the woodwork if something bad happens to him. The guy who got smashed at his corporate holiday event might actually complain in some official way that you violated his civil rights...

End of the day, as cliche as it sounds, the best strategy is probably to do what's best for the patient. That's the only defense that we have anyway.

 

[WilcoWorld]

That's more or less my approach as well.

I think there is no hard and fast rule in terms of what we are liable for or not, except perhaps the one rule that the lawyers can always make it your fault. Its probably both legally wrong to hold them against their will and its probably going to be a successful lawsuit if you let them go and they get hit by a bus. What's the bigger risk depends on what kind of patient you have. The semi homeless habitual drunk is just not going to go find a lawyer to sue you for unlawful detention (or whatever its called), but his family might suddenly come out of the woodwork if something bad happens to him. The guy who got smashed at his corporate holiday event might actually complain in some official way that you violated his civil rights...

End of the day, as cliche as it sounds, the best strategy is probably to do what's best for the patient. That's the only defense that we have anyway.

If you work in NY you have precedent on your side: http://www.wilsonelser.com/news_and...ew_yorks_highest_court_finds_er_physician_and

But, of course, you're right. The above case is no guarantee that you won't get sued.

 

[Angry Birds]

I don't know if I'm getting jaded by too many years in "county" type ED's, or if I'm simply becoming more pragmatic in the light of experience. Last week I allowed a frequent flyer to leave AMA and, when shortly thereafter the EtOH that the resident ordered came back >300, the resident just about panicked. I wasn't too worried and this was vindicated last night when this same patient looked his usual self as he checked in at about 8pm.

Here is how my interaction with intoxicated patients typically goes nowadays:

Me: "I understand that you want to leave. Do you want to hurt yourself or anyone else?"
Patient gives an evasive answer and criticizes the healthcare system/hospital, impugnes my ethics and medical credentials, then makes a comment about my looks.
Me: "Do you want to hurt yourself or anyone else?"
Patient: "No."
Me, as I clear a path between the patient and the exit: "We're here 24/7, come back if you need us."

Then I document something in the chart about how a) Based on the information available I didn't have grounds to hold the patient against his or her will, thereby depriving the patient of autonomy and b) how using force or medications to detain a person against his or her will is probably higher risk than allowing a non-suicidal/non-homicidal person who is walking and talking to leave the ED.

This is exactly my approach.

 

[Birdstrike]

In almost all situations I start with an even smaller dose: 0.04 mg, but I give repeat doses quickly (Q 30 seconds) until the desired effect is reached. Desired effect being breathing at a rate of 8-12 but not necessarily awake. Usually it takes 2-3 doses of 0.04 mg to reach this desired effect. The last thing I want is them waking up and bolting out of the ER and the collapsing again a few blocks down as the naloxone has worn when but the methadone hasn't. The one exception to this practice is when they come in blue/perimortem from a suspected opioid ingestion an unknown time ago, in which case I give larger doses and don't stop until I've given at least 4-10 mg.

This is the correct answer.

 

[BJJVP]

I too tend to start with 0.4mg and then titrate up slowly unless they are in extremis. Going slowly avoids a couple of situations I have had or seen:

1) I have seen a patient wake up in complete withdrawal, vomiting and crapping all over the room. Couldn't get him to stop vomiting. Don't know if he got better after the narcan wore off or if he got admitted. But either way, the nurses were mad and everyone in the ED got distracted.

2) I had a patient once with a multiple drug ingestion aspirate. In addition to the opiate, the patient's suicide attempted included Benadryl, Geodon, Seroquel, valium, etc. I gave narcan and induced withdrawal, followed by yawning and vomiting all while still obtunded from the other drugs ingested.

 

[deleted109597]

The guys at ALIEM touched on this earlier this week as well. https://www.aliem.com/2016/treat-and-release-after-naloxone/
And then Rob Simpson replied in turn. https://ambofoam.wordpress.com/2016/08/27/angling-for-trouble-catch-and-release-for-heroin-overdose/

It doesn't mention dose adjustment, but it does show that in general it's pretty safe to let them go, if they took heroin.

 

[Birdstrike]

Know your opiate 1/2 lives. Methadone can be up to 2-2.5 days. Keep in mind if a known methadone OD, other long half-life opiate OD or unknown opiate OD, in general.

 

[canigetawhatwhat]

2) I had a patient once with a multiple drug ingestion aspirate. In addition to the opiate, the patient's suicide attempted included Benadryl, Geodon, Seroquel, valium, etc. I gave narcan and induced withdrawal, followed by yawning and vomiting all while still obtunded from the other drugs ingested.

I personally would never give narcan here. Tube and icu.

 

[Angry Birds]

Some of the scenarios people have mentioned here make me think I should consider changing my practice. But gosh darn it, I just like seeing a dramatic turnaround so I know the Narcan did something. It's just a lot harder to see with a lower dose.

 

[Apollyon]

Some of the scenarios people have mentioned here make me think I should consider changing my practice. But gosh darn it, I just like seeing a dramatic turnaround so I know the Narcan did something. It's just a lot harder to see with a lower dose.

Yeah, but that "dramatic turnaround"... that was like when I was in military college - "10 guys do the same thing - 9 guys get court martialed, and one guy gets a meritorious service medal".

Not piling on you, but, to be quite honest, 10 years out of residency, I think of all the failures, and so very, very rarely of the successes.

 

[gman33]

Different doses for different situations.

Frankly I rarely get the blue-CPR-in-progress-apneic-peri-arrest-heroin-OD patients anymore due to the penetration of nasal narcan in the community, police force, and EMS/FIRE.
That said if we're to the point of cardiovascular collapse they get 2mg IV or nasal and then another couple doses if it didn't work.

More commonly, we have the bluish-barely-breathing-but-with-a-good-pulse patient. With these I'll do something in the 0.1-0.4mg range IV while we bag them up, up titrating to effect.

Then you have the high-as-a-kite patients, with a RR of 6 who are snoring and have a room air sat of 85%. These get little tiny doses 0.04mg, escalating as needed, to get them safely breathing.

We also have the patients who are altered, polypharmacy patients with unclear histories and sometimes we'll try narcan diagnostically. I typically do that a 0.4mg IV. Sometimes I'll try 2mg IV after if no response.

The issues I have with just slamming 2mg IV into everyone-->
(1) I've seen some nasty post-narcan pulmonary edema with rapid respiratory collapse. Sure you can likely crash intubate them and positive-pressure your way through it, but I'd rather avoid that if possible.
(2) I've seen some nasty post-narcan violence, delirium, and nurse-punching. While cutting off their high might "teach them a lesson", it might also involve me and 5 other staff members playing tackle-the-violent-guy and looking for leather restraints. Certainly we can manage this, but I'd rather avoid that if possible.

If you are going to push 2mg IV, I would suggest preemptively placing solid 4-point restraints and positioning yourself out of punching/biting/spitting range

Never thought of the prophylactic restraint.

Great tip!

 

[alpinism]

Some of the scenarios people have mentioned here make me think I should consider changing my practice. But gosh darn it, I just like seeing a dramatic turnaround so I know the Narcan did something. It's just a lot harder to see with a lower dose.

If you're going to use 2mg go ahead but don't forget to thank our lord and savior Jesus Christ.

Remember the 1st step is love and the 2nd step is mercy.

 

[deleted109597]

If you're going to use 2mg go ahead but don't forget to thank our lord and savior Jesus Christ.

Remember the 1st step is love and the 2nd step is mercy.

Underrated movie, but it's pretty awesome

 

[DeadCactus]

I like the 0.04 mg/mL titrated approach outside of the peri-arrest situation. I see no reason to slam 2 mg in a mild-to-moderate overdose other than spite which doesn't seem to be a good place for decision making to be coming from. Never mind the potential harms of severe withdrawal and adverse side-effects.

Allowing a person with an elevated ethanol level who has capacity on clinical exam to leave is not the same as allowing an inebriated patient to leave and is not the same as pushing a patient into a state of psychological distress by placing them in withdrawal and then allowing them to leave. The studies being recently discussed are reasonable support for not forcefully/chemically restraining a patient who wants to leave but hardly support it as quality care and are even more lackluster in the setting of frequently adulterated heroin.

While there is now precedent to protect physicians in New York, it would be foolish to extrapolate this to other jurisdictions or other intoxicated states.

 

[BJJVP]

I personally would never give narcan here. Tube and icu.

Our initial report was "found unresponsive" and "family thinks he OD'd." His presentation seemed consistent with an opiate toxidrome. We didn't find out about the other drugs until much later.

 

[canigetawhatwhat]

Our initial report was "found unresponsive" and "family thinks he OD'd." His presentation seemed consistent with an opiate toxidrome. We didn't find out about the other drugs until much later.

Touche

 

[UKEMdoc]

If someone wakes up like a screaming banshee after naloxone they definitely aren't intoxicated and leaving the department to score more heroin is almost certainly normal behaviour for them.

 

[Ceke2002]

Also, I'd like to point out that the lowest effective dose of naloxone isn't even 0.04 mg. It's having the vial in your hand and whispering 'narcan...' next to the patient. Sometime's that's sufficient.

OMG, you guys do that as well? That was always our litmus test for when to call an ambulance/get someone to hospital if it looked like the might have dropped - say the word 'Narcan' and see how fast they miraculously recovered.

 

[Ceke2002]

I've never had a patient become violent after Narcan

Coming from real life experience here, so not sure how helpful this will be. Feel free to take as much or as little from it as you will (and sorry this has gotten a bit lengthy as well )

When I was a heroin addict I OD'd more times than I can actually remember, but I was only given Narcan twice (the other times I just eventually came around by myself); and the one and only time I know of where someone did become violent after receiving Narcan was when a (now deceased) friend was trying to commit suicide, and didn't take too kindly to the paramedics bringing him back (he punched one of them in the face and proceeded to attempt to run into traffic). Apart from that I've seen people become agitated, but if the situation was handled properly they calmed down pretty quickly and were usually pretty grateful once they understood what had happened.

When I say 'if the situation was handled properly', I mean trying to make sure that if you've got an agitated patient on your hands you don't end up escalating the situation. The first time I dropped and was given Narcan it was like something out of a movie where the person suddenly gasps back to life. It felt like I'd been slammed back into awareness, and it was a very frightening and confusing feeling to experience (probably made even more so by the fact that I wasn't even an addict at the time, and it was only about the 5th or 6th time I'd even taken heroin). I'm not sure how much Narcan I was given, but I did find out later on that I'd been found unconscious in an alleyway by a passerby (the girl I was with at the time had very kindly done the hell bolt on me as soon as I'd collapsed), the passerby called for an ambulance, the ambos attended, at no point had I stopped breathing, but I was non-responsive to most things except painful stimuli - and then *bam* hello Narcan.

Coming out of an overdose that rapidly, especially when it's the first time you've even experienced an OD, is confusing and bewildering to the say the least, and it certainly doesn't help when your brain is trying to process what's just happened, and you've got people crowding around you and barking orders to 'calm down' (well yes, I might be able to do that if you'd stop raising your voice at me). All I needed was some space to deal with what had just happened; I just wanted to sit quietly by myself for a little while and get my head back in order, while the paramedics backed off a bit and monitored me from a short distance away (like literally 3 feet). And I tried to explain all that, that it was the first time I'd ever OD'd, that I wasn't a regular user (at that stage at least), I was scared, I was confused, I was having trouble dealing with what had happened, and 'please just let me walk over to that wall 3 feet away and sit quietly for a few moments so my brain can process all of this'. But no, their response was to, as I said, keep shouting at me to calm down, and crowd around me, and then start man handling me when it got to the point that my fear and confusion had escalated to where I was openly pleading with them to let me go and trying to get away from them - and it didn't need to come to that.

I found out later on from a friend who was a bit more experienced than I was at the time, based on my descriptions of the ambulance officers who attended, and the name of one of them, that these particular ambulance officers were rather renowned for purposefully antagonising anyone they had to administer Narcan to in order to try and force a reason for police attendance (in South Australia we have a no police call out in place for drug overdoses, unless the person is deemed a potential threat). So yeah, slam the person back to reality, then get in their face and shout at them until the person completely freaks out, and then waste police time and resources when they didn't actually need to attend in the first place; I don't know about anyone else, but that doesn't really seem like the right way to operate to me.

The second time I needed to be administered Narcan was also the last time I ever took heroin. I'd been on the methadone program for about a year at the time, and basically I was an idiot who got so caught up in the fact that I had to visit the dentist for a root canal that I completely forgot to pick up my dose on time, and then rather than stopping to think, "well with the half life of methadone it's not like missing one dose is going to have me curled up in a raging ball of pain at any moment", my brain went 'OMG, I'm gonna start going cold turkey, halp, halp, I need to score' *engage panic mode*. So my husband (then fiancee) reluctantly drove me to score after several phone calls to different friends to try and track down a dealer. We got home, I test dosed a small amount first to try and gauge how strong the gear was - it didn't feel like it was that strong, so I test dosed another slightly larger amount, everything was still fine, and then I took a third dose (which I don't actually have any recollection of) and immediately fell back in the chair, with the needle still stuck in my arm, and stopped breathing (it had been so long since I'd actually used that I completely forgot to take into account that some gear occasionally has a creep to it)

It was the first time my husband had ever seen anyone take heroin, so he didn't really know exactly what to expect, apart from what I'd tried to tell him beforehand, and at first wasn't too sure if this was something normal that happened or not. It didn't take him that long though to realise that 'no, actually this is probably not considered normal', and his fiancee/future wife was in serious trouble (especially with the whole not breathing thing I had going on). So he got me onto the ground, pulled the needle out my arm, phoned for an ambulance, and started mouth to mouth - when the ambulance turned up they immediately started bagging me, and administering Narcan. Apparently when I hadn't come round after the fifth dose they were just bringing the stretcher through to rush me off to hospital when they noticed a faint flicker across my eyelids, and I finally took a couple of shallow breaths on my own. At that point they waited a bit, kept bagging me to help with my breathing, obviously kept me under pretty close observation, and I very gradually regained consciousness. Coming out of that overdose was completely different to the way I came out of the first one - rather than feeling like I'd been slammed back into reality, this was more like very slowly waking up from a deep sleep. I did get a bit upset and embarrassed when I finally realised what had happened, but in contrast to the way my first overdose was handled, the paramedics this time did everything they could to reassure me and give me some quiet space whilst still making sure I was okay and doing what they needed to do. They were fantastic, very reassuring and calming, which helped me to recover quicker and resulted in them having an extremely grateful patient on their hands, rather than a terrified, confused, and increasingly agitated one.

Bottom line, some patients are going to just be unco-ooperative a-holes who want to up and leave to score their next hit the moment they wake up, some will probably be p!ssed off and belligerent that you ruined their 'high', but a lot more are probably just going to be confused and scared and will co-operate given some space and reassurance.

 

[deleted547339]

I see no reason outside of a true arrest to ever slam narcan in. The pathology is primary respiratory arrest. You can always bag an opiate-OD patient up. Titrate narcan while bagging. And honestly, in a full arrest, I don't see a role for narcan. Again, primary respiratory arrest needing O2 and an airway. If the patient comes back with bagging then ETT, great. I don't to prophylactic restraints, but I usually don't wake these people enough so they can have a conversation. More than one dose of narcan and I intubate. I see no reason for a narcan drip - think you have a lot more to lose by screwing up that than putting someone on the vent and letting them wake up the next day.

 

[WildcatS11]

I see no reason outside of a true arrest to ever slam narcan in. The pathology is primary respiratory arrest. You can always bag an opiate-OD patient up. Titrate narcan while bagging. And honestly, in a full arrest, I don't see a role for narcan. Again, primary respiratory arrest needing O2 and an airway. If the patient comes back with bagging then ETT, great. I don't to prophylactic restraints, but I usually don't wake these people enough so they can have a conversation. More than one dose of narcan and I intubate. I see no reason for a narcan drip - think you have a lot more to lose by screwing up that than putting someone on the vent and letting them wake up the next day.

Respectfully, I think that's crazy. You have a drug that is legitimately the antidote for this situation. If you're confident this is an opiate OD, you would have little ground to stand on by not using narcan. Narcan has few true adverse effects, especially when used responsibly. How exactly do you screw up a nalaxone drip?

However, an endorses heal intubation, especially on someone who it seems has been bagged for a few minutes, has legitimate risks. As does the ventilator for a few days.

Now I'm all for securing the airway early and often, but a pure opiate overdose seems to be one of the times to show some restraint. Reverse the cause first.

 

[Angry Birds]

Respectfully, I think that's crazy. You have a drug that is legitimately the antidote for this situation. If you're confident this is an opiate OD, you would have little ground to stand on by not using narcan. Narcan has few true adverse effects, especially when used responsibly. How exactly do you screw up a nalaxone drip?

However, an endorses heal intubation, especially on someone who it seems has been bagged for a few minutes, has legitimate risks. As does the ventilator for a few days.

Now I'm all for securing the airway early and often, but a pure opiate overdose seems to be one of the times to show some restraint. Reverse the cause first.

Agreed one hundred percent. If I was the oncoming ER doc and took over a patient who was intubated because Narcan wasn't given, I would be really judgmental.

 

[deleted547339]

Agreed one hundred percent. If I was the oncoming ER doc and took over a patient who was intubated because Narcan wasn't given, I would be really judgmental.

I didn't say I wouldn't give narcan, I said I won't slam it in - big difference. I was simply saying I don't see utility in giving a massive dose.

As far as a narcan drip, I think it's safer to have someone intubated for 6-12 hours than have an RN have to titrate a drug that he or she is not firmiliar with. Plus, there is an inherent subconscious (or conscious) desire to let a narcan drip run light so the RN can have a quiet night. Am I never advocated having a patient on a vent for days - I'm talking putting them in the unit and extubated in 6 hours. Would need the same unit bed for a narcan drip anyway.

As far as a true cardiac arrest, if a hypoxia arrest has progressed to cardiac arrest, giving narcan won't fix that. You need oxygen and pump support, not opiate reversal.