"Just 2"

[docB]

So EMS just walked in the door with a screaming, agitated, combative patient wearing a spit mask. I asked what his problem is. I was told by the medic it was a narcotic OD. "Narcotic OD?" I asked, "Sounds more like meth."

I though about it for a second and looked at the young medic. "Did you give him Narcan?" I asked.

"Just 2."

I have noticed over time that a medic's usual Narcan dose is inversely proportional to his years on the street. A twenty year medic starts with 0.4 or less and titrates up from there.

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[proman]

Completely agree. I remember one patient in Atlanta (he was an NA counselor at a meeting) where I had breathing after 0.4mg. The EP insisted me giving 2mg, so I waited until right before we unloaded the patient on the ramp and pushed the rest. Now the ED had to deal with a violent pissed off puking patient.

I'll give 40 mcg (0.04mg) as my first dose. The second dose is 80 mcg (after waiting 2 min or so). Obviously I don't deal with recreational overdoses. The patients that I use Narcan on are usually the ones that I've accidentally overdosed.

 

[leviathan]

The guidelines at my old job were to give 0.4 mg IV or 0.8 mg IM. I've never heard of anyone needing 2 mg...

 

[deleted6669]

with large overdoses or long acting agents you may need high doses and perhaps even a narcan drip but I agree that the simple heroin o.d. can do fine with smaller doses.

 

[EMS5]

I remember my first narc OD...unresponsive/barely breathing when we arrived, pushed .4 of narcan on scene, by time we were in the ambo there was no improvement so we pushed the other 1.6 and boy did he come back fighting...first and last time a patient has received 2 of narcan from me

 

[Apollyon]

We would always do "1 and 1". Actually, I would often do just 1mg. I always thought it was quite the ***hole move to give 1mg at scene, then push the 2nd mg in the ambulance bay. Maybe I was too evolved at an early age, but I didn't think it was funny to give the ED a patient whose buzz has been harshed.

edit: before anyone gets offended, this is not directed at anyone in this thread. I just remembered various partners from the 90s.

 

[tkim]

Used to give 2 - 1 IM then 1 IV. The 1 IV was enough to wake them up they could sign AMA, the 1 IM was so that they could walk far enough into another district before they went down again, so we wouldn't have to pick them up twice.

 

[proman]

We would always do "1 and 1". Actually, I would often do just 1mg. I always thought it was quite the ***hole move to give 1mg at scene, then push the 2nd mg in the ambulance bay. Maybe I was too evolved at an early age, but I didn't think it was funny to give the ED a patient whose buzz has been harshed.

edit: before anyone gets offended, this is not directed at anyone in this thread. I just remembered various partners from the 90s.

The jackhole was the one sitting at the radio giving the order (which I didn't need because we had a protocol for it).

 

[Apollyon]

The jackhole was the one sitting at the radio giving the order (which I didn't need because we had a protocol for it).

As I said, I was not referring to you. I was referring to *** ****** and others (people with whom I worked). We had up to 2 mg on protocol, and they were the ones who would blow the second mg in while in the ambulance bay.

Again, not you.

 

[MedicFL]

JUst because someone gave you an order online or via written doesn't mean it has to be followed to the T. If you pt does not require all 2mg just document it in your report and there should be no problems..

 

[chimichanga]

JUst because someone gave you an order online or via written doesn't mean it has to be followed to the T. If you pt does not require all 2mg just document it in your report and there should be no problems..

Giving less than ordered, is, in my opinion, prescribing...Just as giving more is certainly prescribing...we all agree on THAT one, right?

Let me qualify: You can give less, but the order needs to be changed/clarified later (and discussed w/ prescribing doc)

floor nursing tries doing this all the time...no prob, just tell the doc, and be prepared to justify why the discretion; problem is, most RNs think they don't have to tell the doc...WRONG!!!

thoughts?

 

[deleted6669]

Giving less than ordered, is, in my opinion, prescribing...Just as giving more is certainly prescribing...we all agree on THAT one, right?

Let me qualify: You can give less, but the order needs to be changed/clarified later (and discussed w/ prescribing doc)

floor nursing tries doing this all the time...no prob, just tell the doc, and be prepared to justify why the discretion; problem is, most RNs think they don't have to tell the doc...WRONG!!!

thoughts?

most well written field protocols give the medics a range to deal with( narcan 0.4-2 mg IV/IM/SL ).
it's the rare medic nowadays who has to request orders anymore. most calls are notifications; pt had this, we did this, c'ya in 5.

 

[Altruist]

Giving less than ordered, is, in my opinion, prescribing...Just as giving more is certainly prescribing...we all agree on THAT one, right?

Let me qualify: You can give less, but the order needs to be changed/clarified later (and discussed w/ prescribing doc)

floor nursing tries doing this all the time...no prob, just tell the doc, and be prepared to justify why the discretion; problem is, most RNs think they don't have to tell the doc...WRONG!!!

thoughts?

Yeah the whole "mother may I" protocol system for EMS is pretty rare these days. Many systems have tried to move to reserving online med control for complicated cases. I agree with you about floor nurses, but in practice EMS providers tend to be given a bit more leeway. I'm not sure that's "right" by the letter of the law, but it's what happens.

As far as the original topic, I learned pretty quickly that 0.4 (at most) brings back breathing; 2 mg = Lazarus re-enactment (usually with puking). You only have to make that mistake once.

 

[EMS5]

Yeah the whole "mother may I" protocol system for EMS is pretty rare these days. Many systems have tried to move to reserving online med control for complicated cases. I agree with you about floor nurses, but in practice EMS providers tend to be given a bit more leeway. I'm not sure that's "right" by the letter of the law, but it's what happens.

As far as the original topic, I learned pretty quickly that 0.4 (at most) brings back breathing; 2 mg = Lazarus re-enactment (usually with puking). You only have to make that mistake once.

+1

 

[fiznat]

Our protocols give a range as well, which pretty much translates into "whatever you think the sweet-spot dose is between 0 and 2 mg, repeat if necessary."

If I've got an IV I'll start with 0.4 or so depending on how out of it they are. If I have to go IM I'll start with 1 or even 2 sometimes. Haven't played with the IN route yet.


I did a bunch of my shadowing hours in one of the same EDs I routinely transport to, and I was amazed at how often crappy medics will come in having done the wrong thing (or omitted the right thing). No wonder EMS gets the reputation they do. There are just too many *****s and not enough follow up.

 

[proman]

JUst because someone gave you an order online or via written doesn't mean it has to be followed to the T. If you pt does not require all 2mg just document it in your report and there should be no problems..

That's not how it works. As soon as the EP gave a direct order, protocols are no longer in effect. I know my medical director would have backed me up but my administration would not have. This guy had a history. He got what he wanted.

 

[leviathan]

As far as the original topic, I learned pretty quickly that 0.4 (at most) brings back breathing; 2 mg = Lazarus re-enactment (usually with puking). You only have to make that mistake once.

I found that 0.4 IV will help respiratory drive; another 0.4 mg IV at the hospital (by order of the MD) will cause the patient to lose control of their bowel functions for the poor nurse to clean up.

 

[chimichanga]

... As soon as the EP gave a direct order, protocols are no longer in effect. I know my medical director would have backed me up but my administration would not have.

Agreed w/ EP trumping offline protocol, but one should always have some sense of clinical discretion on scene, in discussion w/ the EP, irrespective of admin...

Example: EP gives verbal for morphine 4mg IV for ortho injury, but pt well controlled after 2mg...

 

[Paseo Del Norte]

Agreed w/ EP trumping offline protocol, but one should always have some sense of clinical discretion on scene, in discussion w/ the EP, irrespective of admin...

Example: EP gives verbal for morphine 4mg IV for ortho injury, but pt well controlled after 2mg...

This is an interesting point. I have only had to call a couple of times on cases where I was either stumped or had a situation where there was a grey area. (Pregnant, premature labour patients were sometimes on the line with our clinical practice guidelines). However, I would take a verbal order from a physician as stated and only use discretion if the physician allowed me to do so. (In other words, order > Protocol in most cases.) Otherwise, I would follow the order as stated unless it was clearly dangerous. Of course, this has never occurred thus far.

In the example, I would go ahead and give the 4 mg unless there were pretty clear indications that giving said dose would cause harm. We give pretty liberal doses of fentanyl to our ortho injuries, so I would be comfortable giving most adults who were otherwise healthy 4 mg of morphine.

 

[chimichanga]

In the example, I would go ahead and give the 4 mg unless there were pretty clear indications that giving said dose would cause harm. We give pretty liberal doses of fentanyl to our ortho injuries, so I would be comfortable giving most adults who were otherwise healthy 4 mg of morphine.

It's just that reading the thread got me thinking...

I always ask if they've had morphine (for example) before (non cardiac pts, and "higher" doses)...If they say "no" I will start w/ 2 mg, wait for their response, and then decide on the rest (75% of the time, I'll give the rest w/in a couple of minutes)


Once in a while, the pt will be in left field after the 2 mg, and pain is controlled...Then I stop, go right to the ED doc, let him know the details, and we usually stop there, then he changes the order...

Nursing discretion...No "clear indications" as Paseo mentions, only 20 years of seeing what 6 mg of MS or whatever can do to some patients (morphine virgins specifically)...Come to think of it morphine is the only med I've done this with...

Now, what I was referring to otherwise was, I have talked w/floor nurses who only give 2 because "well, I think four is too much for this person" and then she doesn't discuss this w/ prescribing doc (or even make a note in the comm section )...That's prescribing, as the doc thinks that his pt is always getting 4...

Clear as mud?

 

[Paseo Del Norte]

I agree, you are basically prescribing without a license to practice medicine IMHO. If you put the patient out after two milligrams, I think it would be reasonable to stop giving the med and let the doc know that 2 mg put the patient into halcyon land. Of course, you and I both agree that communicating this to the physician is the vital missing link.

However, I must admit my floor experience is limited to the time I did on the floor as a nursing student. The rest of my career has either been in the ER, a remote clinic or medical evacuation. So, I am fairly comfortable giving doses that some nurses may be uncomfortable giving. It was not uncommon for me to receive orders for 10 mg of morphine (had a doc that liked to give 0.1 mg/kg) and I frequently start off with 100 mcg of fentanyl and work my way up if my patient continues to be uncomfortable.

 

[JLM]

2 mg of narcan is TOO MUCH on most patients. Im guilty, I used to slam narcan on the junkie in the alley. But, now I know It is NOT a benign drug. Straight from Barash Clinical Anesthesia (our residency's primary text):


'Sudden, complete antagonism of opioid effects with naloxone can cause severe hypertension, tachycardia, ventricular dysrhythmias and acute pulmonary edema.'

This is not a theoretical risk. There are studies showing huge catecholamine surges when opiates are quickly reversed.

Let your partner ventilate. Pull up 9cc of saline or LR from your IV bag. Dilute that 0.4 mg vial in those 9 cc which gives 0.04 mg/cc. Give 1cc every min (give it the full min, it has to run in and reach the receptors) until the patient is breathing and responds to verbal stimuli but still sleepy. There is NO NEED to completely reverse the usual heroin overdose unless they are in cardiac arrest.

When I give grandma too much fentanyl in the OR, it usually only takes 0.08 mg to get her breathing again and keep her comfortable. Not true of every case, but the vast majority.

 

[TarHeelEMT]

It depends. If they're getting it intranasally, then they're getting a lot more than if I give it IV.

 

[proman]

It depends. If they're getting it intranasally, then they're getting a lot more than if I give it IV.

What do you mean by this?

 

[Paseo Del Norte]

I think he is talking about the MAD device as it's called in my area of the world. It's a way of delivering naloxone via the nasal route as an alternative to IV. The companies that use it in my area seem to have default protocols that state 2 mg.

A little more information:

http://intranasal.net/OpiateOverdose/

Midazolam is also given by this route in some areas. Took care of a family in the ER a while back who had a child with a seizure disorder. They had administered it at home to this particular child, so this modality is apparently in the hands of lay people as well.

 

[malkboy]

I even remember hearing/reading about police officers that were issued pre-filled narcan MAD-syringes.

So whats your experience with narcan via MAD? I've never used it for narcan, only fentanyl and versed so far.

 

[proman]

I think he is talking about the MAD device as it's called in my area of the world.

Yeah, they're great. I use them to with lidocaine to topicalize the airway for awake intubations.

It depends. If they're getting it intranasally, then they're getting a lot more than if I give it IV.

This statement implies that the intranasal administration results in more drug being administered vs. IV. I just want TarHeelEMT to clarify what he means because that isn't the case.

 

[jwk]

Yeah, they're great. I use them to with lidocaine to topicalize the airway for awake intubations.



This statement implies that the intranasal administration results in more drug being administered vs. IV. I just want TarHeelEMT to clarify what he means because that isn't the case.

Hopefully he means he's "giving" a lot more to get the same effect, whici is correct, as opposed to "getting" a lot more, which is incorrect.

 

[jwk]

As far as the original topic, I learned pretty quickly that 0.4 (at most) brings back breathing; 2 mg = Lazarus re-enactment (usually with puking). You only have to make that mistake once.

That's the whole idea.

2 mg of narcan is TOO MUCH on most patients. Im guilty, I used to slam narcan on the junkie in the alley. But, now I know It is NOT a benign drug. Straight from Barash Clinical Anesthesia (our residency's primary text):


'Sudden, complete antagonism of opioid effects with naloxone can cause severe hypertension, tachycardia, ventricular dysrhythmias and acute pulmonary edema.'

This is not a theoretical risk. There are studies showing huge catecholamine surges when opiates are quickly reversed.

Let your partner ventilate. Pull up 9cc of saline or LR from your IV bag. Dilute that 0.4 mg vial in those 9 cc which gives 0.04 mg/cc. Give 1cc every min (give it the full min, it has to run in and reach the receptors) until the patient is breathing and responds to verbal stimuli but still sleepy. There is NO NEED to completely reverse the usual heroin overdose unless they are in cardiac arrest.

When I give grandma too much fentanyl in the OR, it usually only takes 0.08 mg to get her breathing again and keep her comfortable. Not true of every case, but the vast majority.

Ditto. The concept of "if a little is good a lot will be better" does not apply to Narcan. That sudden sympathetic rush can cause it's own huge set of problems.

 

[Dwindlin]

I usually give them just enough so they are breathing and maintaining their own airway.