Noloxone...should EMT-I's be able to administer?

[hammerpcp]

At the risk of putting my other foot in my mouth..........I have a few questions/concerns. Firstly to my understanding, when Naloxone is administered it is titrated slowly to the point of desired clinical effect, namely reversal of respiratory depression. I also thought that this was a fairly reliable response. Meaning that if you administer it in this fashion rather then 2mg all at once the chances of inducing any significant withdrawal symptoms are close to nil. If the afore mentioned is true, then the risk-benefit balance is heavily weighed on the benefit side of things, which supports the administration of Naloxone by PCP+'s in areas where there is high prevalence of narcotic use (like Brat).

Also, from what I have read, again I don't have much first hand experience with this drug, the incidence of seizure post Naloxone admin is rare. And the risk can be minimized by gradual administration as well. It also sounds like adverse cardiac effects have been known to occur for the most part in individuals who have preexisting cardiac conditions, or have been receiving cardio toxic drugs during surgery etc. In this case the Naloxone is used in or post OR.

I am having difficulty finding information, research or anecdotal, that clearly states the occurrence rate and severity of the adverse reactions, so it is very difficult to weigh the risks versus benefits of this drug accurately. If any one has any data please share, it may win you this debate.

Another thing to consider is the adequacy of the BLS treatment/management of respiratory depression/arrest. How efficient is BVM ventilation when the pt is not intubated? And one must also consider the potential complications of this, e.g.: vomiting; aspiration; gastric insufflation; inadequate oxygenation; hypoxia/hypoxemia. Ventilating a pt via BVM with an oropharyngeal adjunct is not equivalent to the pt breathing spontaneously on their own.

In conclusion.........Am I dumb?

[Lithium]

Alright, this really doesn't seem to be going anywhere ... here's my two cents.

Brat, I don't agree with you on this one. For one, to my understanding, North Bay has ALS providers available. I realize they're few and far between, and only in the city, but still, they're still there. That's what this whole debate was about, was for services without ALS allowing their EMT-Is to give this drug. You have ALS available, therefore although you may not be able to give it, the patient has a chance of receiving it prehospitally.

nsmedic, I would disagree with you as well. As much as I am about the ABCs, if I can reverse a problem, I will. When I was in ACP school, I failed 2 scenarios because I kept giving Narcan through the IV. I then realized what my instructors were trying to impress upon me ... there is other routes available (IN, IM or SC). So, I began titrating through IM, and no more failed scenarios. I've seen and administered narcan in various routes, and above all, I prefer giving 0.4 mg IM q 2min PRN. We're capped here in Ontario at 2 mg anyways, but that's okay. If they need more then 2 mg, I would rather them receive it in a more controlled setting then the back of my ambulance where it's me and maybe a firefighter or student.

Dustdevil, YES! I say we eliminate the PCP provider. I'm all for an ALL ALS system, but that's a far ways away. However, to clarify for you ... Ontario has a provincial set of protocols for PCPs and ACPs. Each service and base hospital usually adopts those with limited (and in some cases no ... haha hammerpcp) changes. In certain cases, some services have added their own protocols to meet the needs of the community (which I'm completely for). These services Base Hospitals then provide additional teaching and CE points for whatever additions they've made. The problem with this, is it prevents certain opportunities from becoming available in the long run. Oh well .. that's the way the system works.

Hammerpcp, I agree with you to a point. I'm all for developing protocols to meet the needs of the community, however, if they want ALS interventions, they should design a system to support ALS medics. (yes, my dream one day would be to have ACPs on every car, and CCPs doing intercepts for those high profile CTAS 1s and 2s ... haha i know, im nuts). When it comes down to it, I personally don't feel PCPs should even be starting IVs. (let the flaming start!) Paramedicine is not a perdiem industry. IV initiation and maintenance is a very invasive procedure, and the way services are justifying it scares me. "well, our pcps do IVs so they can give D50" pardon me? Have you actually ever seen what happens when D50 extravates? Yes, if given correctly, it can be a lifesaving intervention. But, what are you gonna do if that IV becomes interstitial, you didn't know and you just pushed a whole tube of go-go juice? Watch the guys arm fall off ... nice. Now, I'm not saying there's more I can do for that, EXCEPT we do have access to pain control .. do you? So now the justification is to add morphine or fentanyl or perhaps a benzo, just in case. Just like Dustdevils argument (which I loved) ...

"I want Narcan just in case."

"Narcan causes seizures? Well then I want Valium, just in case!"

"Valium causes apnea? Well then I want Romazicon, just in case!

"Romazicon causes arrhythmias? Well then I want ACLS drugs just in case!"

It should be all or nothing, and if communities, municipalities, districts and the MoH can't see that ... WE need to enlighten them.

[paramedicmike]

Well said Lithium (and Dust to have it recapped here).

-be safe

[Scaramedic]

I agree with you Hammer the incidence of complications with Narcan are almost nil if it is administered properly. My experience with Narcan (I hate typing out Naloxone) is bringing the pt up to a point just below verbal works the best, no fighting, no N/V and more importantly you can actually get them to a hospital. Which brings up a point that has not been discussed, the half life of Narcan vs the half life of opiates.

Narcan's half life is shorter than opiates, so another danger of bringing your pt. to fully awake is a majority of them will refuse transport. This creates a situation where they may slip back into resp. depression, depending of course on the purity of the opiate they were using. That is where an old school trick comes into play. Forgive me if this is not done any more, I have been off the streets for five years. If someone refused transport we would also give them IM Narcan on top of the IV dose. The idea being that it would stretch the antagonist effect out long enough for the Opiate (who am my kidding, the Heroin) to be used up in their system. So Lithium that might be why your instructors were pushing you to think about other routes.

So who should be allowed to administer Narcan? I do not believe Basics should be using Narcan, sorry guys I love Basics but this drug is not for you. If administered properly it is safe, but I am a worse case scenario kind of guy. Being administered incorrectly is what concerns me, Para's can deal with the screw up Basics can't. I do not consider running code 3 to the hospital a proper intervention for a bad dosing of Narcan. I do not have much experience working with Intermediates, I have only worked in dual Medic systems or Medic/Basic systems, so I do not know much about the Intermediate level. So as far as Intermediates and Narcan go, I will withhold my judgment. PCP's, I am going to claim being a stupid American on that one, I have no clue what a PCP is, maybe someone can explain that one to me somebody. :-#

So that's my .02 on this issue, I do love the discussion though.

Peace,

Marty

:thumbleft:

[Lithium]

haha ... Scaramedic, actually, I think it was because I was pushing the narcan too fast. I'd draw up 2 mg, stick it in my IV port and try and do a slow IV push over about a minute.

Both times, my patient began convulsing about 30 seconds in, and the first time I was like "what the hell!? :shock: " I admittedly went for my diazepam and the seizure broke. Second time (you would have thought I'd have leart by now eh) I was like "ahhh crap, this again".

I'm well aware of the effects of an acute withdrawal.

peace

[hammerpcp]

OK folks lets do a reality check here. We have basics or EMTs or whatever because of the bottom line. You educate people more you have to pay them more.

Lithium, stop laughing at us Hammertonians. Don't judge us because we have mullets and no teeth and really like Tim's.

Anyway, if I understand you correctly you are saying that PCP's should not give Narcan because they do not have the capabilities to deal with potential side effects. (It just occurred to me that you could administer morphine to someone experiencing seizure from acute opiate withdrawal and it would probably be much more effective then just suppressing the seizure with valium. But I guess you would then, technically, be a drug dealer.)

The problem with your logic is two things 1) there is always a higher level of care, I'll borrow something that is already mentioned....ALS medics have Valium but do not carry romazicon. Same situation, no? And 2) As I stated earlier, as far as drugs go Narcan is pretty benign and the chances of actually inducing life threatening adverse reactions is actually low. (If administered properly) 8)

[Ridryder 911]

Is it just me or is this thread going no where fast... amazing the vote is pro EMT- I's administering it, but no major rationale as of yet.

So what have we learned:

Medications should be administered by ALS educated personal

Medications although intent is good for the patient can be BAD!

Narcan as benign as it seems, can be dangerous to patients

Administering Narcan non-appropriately can be harmful to your patient, you and your partner

Some EMT/I's on this site either can not logically debate on why they should be allowed to administer the medication, or have no backbone to debate it. Therefore we have to assume that they are whackers and want to "push" a medicine, so they have something more to do on a call.

Be safe,

R/r 011

[Lithium]

Hammer; Yes, I agree with you. I'm well aware that there is always a higher level of care. This is one reason why I want EVERY ambulance to be ALS, with CCPs doing intercepts. This is purely a Canadian training thing, but still.

Secondly, although I do not have flumazenil at hand to counteract the potential apnea received from one of the benzos I may elect to give, I do have at my disposal advanced airway management techniques (ETT, LMA, surgical cric to name a few) as well as a thorough and comprehensive understanding of respiratory physiology and airway maintenance procedures. Not only that, if I'm administering this medication, I can anticipate any side effects and include that in my prealert to the receiving facility.

Third, as scaramedic stated, Narcans half-life is MUCH shorter that most opiates. So perhaps in an extreme case, if I'm transporting this terminal cancer patient (come on, let's get away from the stereotypical heroin junkie) who's overdosed on their morphine, purely out of a palliative attempt, and I've maxed out my protocol, I still can ensure proper airway management through intubation. Can you?

And, my logic is not flawed thank you very much. My logic is as follows: "Not always right, but never unsure."

peace

P.S. Trust me, you're not the first to have thought of the 'morphine for withdrawal'

edits: TOO many spelling errors

[Nate]

Some EMT/I's on this site either can not logically debate on why they should be allowed to administer the medication, or have no backbone to debate it. Therefore we have to assume that they are whackers and want to "push" a medicine, so they have something more to do on a call.

Be safe,

R/r 011

We could just label a saline flush as Narcan and let them think they are pushing something important.

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