Nasal Narcan? What else?

[firedoc315]

In my experience the slower you push the plunger the more fluid will drain out. The entire concept is to atomize the liquid, which means a FAST expulsion of the liquid, therefore the drug. Our practice is to administer 1/2 to 1 cc in the nostril. The onset is virtually the same as IV if used correctly.

I will withhold comment on the last part of your post, except to direct your attention to Steve Barry's recent JEMS cartoon regarding defibrillation. EMS as a joke? ? ?

[Bags]

Not sure if you have this already, but here is an Australian study looking at prehospital IN fentanyl.

Rickard, C., O’Meara, P., McGrail, M., Garner, D., McLean, A., & Le Lievre, P. (2007). A randomized controlled trial of intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting. American Journal of Emergency Medicine, 25.

[john51071]

I have had the chance to use IN Midazolam on seizing patients 3-4 times since 2004. It works rapidly and well, and as mentioned by others, is much safer to #1 than an IV stick. Have not had a chance or reason to use IN Narcan, but then again, I almost never use it anyway. I think Nasal Atomization of these meds is a great benefit to any service, for safety alone.

[UMSTUDENT]

We have had it in our service here for about 3-4 years. It's been done a few times with Versed but none that I know of for Narcan or Fentanyl yet. I have not heard any complaints from anyone that has done any of the IN administrations. Some of this reason could be that we have been going down the path of airway management for narcotic overdoses and not giving Narcan unless the patient is hypOtensive as well. I like this because now the medical residents in the ER and the nurses have to do all the wrestling instead of us. :wink:

Oh lovely, another misnomer of our profession. You shouldn't be wrestling with your patient following the administration of Narcan. I personally believe this is one of the most poorly utilized drugs in EMS.

I had this argument with a paramedic from another service a while back. Their service would automatically intubate any patient with respiratory distress, regardless if they had a strong suspicion of narcotic overdose. Then, they would push that naxolone, the patient would wake-up, pull the tube, and get super pissed off.

Naxolone should be gauged based on desired effect. Do you really need to push 2 mg on every patient? Probably not. For some reason we push it like candy in EMS. "What you took some HER-ION?" "Let's slam 2 mg of Narcan 'cause that was what I was taught in class 15 years ago!"

If you strongly suspect Narcotic overdose, you probably don't want to get rid of any sedative effects (situation dependent). Push to increase respiratory sufficiency, maybe bring them out-of-it a little, and let them be. When you slam Narcan you have the risk of causing sudden withdrawal, seizures, and tremors (I see this a lot). You piss your patient off, they get violent, and you cause everyone more problems than it is worth. Granted, I understand that there are some patients who have an "all or nothing" reaction to the drug. Likewise, some patients legitimately require intubation and respiratory support, but you have to increase the sophistication of your assessment and utilize this skill as appropriate.

Note:Obviously, follow your protocols. But if you can, and you're allowed, just be cautious with the administration. Remember: Do no harm.

[Arizonaffcep]

Oh lovely, another misnomer of our profession. You shouldn't be wrestling with your patient following the administration of Narcan. I personally believe this is one of the most poorly utilized drugs in EMS.

I had this argument with a paramedic from another service a while back. Their service would automatically intubate any patient with respiratory distress, regardless if they had a strong suspicion of narcotic overdose. Then, they would push that naxolone, the patient would wake-up, pull the tube, and get super pissed off.

Naxolone should be gauged based on desired effect. Do you really need to push 2 mg on every patient? Probably not. For some reason we push it like candy in EMS. "What you took some HER-ION?" "Let's slam 2 mg of Narcan 'cause that was what I was taught in class 15 years ago!"

If you strongly suspect Narcotic overdose, you probably don't want to get rid of any sedative effects (situation dependent). Push to increase respiratory sufficiency, maybe bring them out-of-it a little, and let them be. When you slam Narcan you have the risk of causing sudden withdrawal, seizures, and tremors (I see this a lot). You piss your patient off, they get violent, and you cause everyone more problems than it is worth. Granted, I understand that there are some patients who have an "all or nothing" reaction to the drug. Likewise, some patients legitimately require intubation and respiratory support, but you have to increase the sophistication of your assessment and utilize this skill as appropriate.

Note:Obviously, follow your protocols. But if you can, and you're allowed, just be cautious with the administration. Remember: Do no harm.

I dare say that's the biggest risk of pushing narcan too fast.

[fishman]

We are able to do IN Fentanyl, Narcan, and Versed. Metro Indy area. All seemed to work well. Real nice with poor vein status and such. Gives time for some treatment, then work on access.

[Fox800]

We have protocols for the following IN drugs:

Fentanyl 1-2 mcg/kg

Versed 5mg

Naloxone 2mg

Glucagon 1mg

I've had mixed results with the fentanyl and versed. Haven't given naloxone or glucagon IN yet.