Benzo Overdose

[usalsfyre]

Brave flight crew. I'd have just stuck the tube and gone on, having managed a seizing patient in an aircraft it's not fun.

You'll find it's very easy to manage most patients for a few minutes longer. A 30 minute transport is not that long, but you see these patients getting flown all the time, when in reality you probably add 15 minutes to the transport by calling for air.

[chbare]

I think there are valid points. Not every patient needs to go to a large, sub specialty centre. A community hospital with a reasonably well equipped ICU can manage patients like this. Clearly, this comes down to a judgement call. Also, not every patient needs air transport. In fact, the evidence is a crap shoot as to if flying significantly impacts outcomes. There does exist some trauma related evidence, but I'm not aware of evidence that pertains to this scenario. In addition, restricted access and operations at altitude can present with significant challenges. Aeromedical teams do not like to intubation in the air for these very reasons.

I'm not so sure about the safety implications as ambulance crashes are not uncommon, but still, I believe we have points that are worthy of consideration.

[croaker260]

Flumazanil is right up there with Satanisim .... far better to provide good oxygenation/circulatory support and take to hospital

I done about reckon we should be doing the same for most ODs and shouldn't really be waking them up with naloxone

Agreed. We used to carry it here in the late 90's, until we decided that it ws far better to intubate them than giving Romazicon. As a general rule , isolated benzo OD's are best managed supportively. If its a poly pharm, then the Benzo's are doing way more good than harm, and again supportive/airway management is the order of the day. similar to narcan, you can cause more problems than you solve with poly pharm ODs and romazicon.

A little side note: Anyone know what the ORIGINAL brand name was (before ROmazicon?).

Reversed. Say it slowly...Re-ver-sed. get it?

Edited November 25, 2011 by croaker260

[tcripp]

Speaking of naloxone...learned an interesting way to administer it instead of IV/IN...nebulized Narcan. By applying it in this manner, you will know when it's titrated to effect as the patient, most likely, will move the mask from his/her face once he's regained consciousness.

I think I like this as an option if I'm going to give it.

[chbare]

If you have a patient with a depressed respiratory drive, I assume optimal inertial impaction and deposition of nebulised naloxone would be compromised. I would also have concerns about the potentially wide range of bioavailability when given via the nebulised route. Of course, the IN route appears to have good efficacy. What does the literature say about administering naloxone this way?

[tcripp]

Well, one study is as follows: http://www.ncbi.nlm....ubmed/12609650

And, what I should have said above? "Since my service does not offer IN as an option, I like this as a plan B."

Also, if naloxone is accepted as an ET drug, why would there be concern about a neb treatment?

edited to remove the "." from the link.

Edited November 25, 2011 by tcripp

[Eydawn]

"Page not found"- your link is funky...

Chbare, what are your concerns with the bioavailability stuff? If you're thinking it's going to take longer, because it's less bioavailable or they're not drawing it in far enough to really hit good absorptive mucus membranes, what's the real concern? Eventually, they will get enough doseage to wake them up enough to have good respiratory control, which is our goal with naloxone, no? So it takes a couple minutes longer... but it is more patient response regulated, as the patient begins to wake up, as opposed to potentially overshooting with the IN or IV route and ending up with a really pissed off patient...

Just curious as to what the real concern here is other than extended time and loss of drug- as long as the patient gets the amount necessary to create our desired effect, I don't see what the issue would be.

Wendy

CO EMT-B

[tcripp]

Because the city included the "." in the hyperlink.

Try http://www.ncbi.nlm.nih.gov/pubmed/12609650

[chbare]

ET administeration is not the same as nebulised. If you have an apneic, unresponsive patient, I do not think they will have a respiratory pattern that permits good absorption and bioavailability. If the patient has a good respiratory pattern, I would question the need to even give naloxone. I'm not arguing against this route per se, but if we have a patient that is apneic, I'm not sure of the efficacy of administering it via this route. I have seen a few case studies involving lethargic, methadone overdoses that were successfully treated; however, I am not sure that this route would be appropriate to use universally. Special cases perhaps.

Of course I must admit my bias about reversal agents such as naloxone. I like to give small doses and titrate carefully for effect. I'm not sure how easily I could do that in certain patients via the nebulised route. Perhaps a consideration in certain cases, but I'm not sure it would be successful in all cases. I guess you could intubate and bag the neb in, but the whole point is to prevent intubation if possible?

[tcripp]

ET administeration is not the same as nebulised. If you have an apneic, unresponsive patient, I do not think they will have a respiratory pattern that permits good absorption and bioavailability. If the patient has a good respiratory pattern, I would question the need to even give naloxone. I'm not arguing against this route per se, but if we have a patient that is apneic, I'm not sure of the efficacy of administering it via this route. I have seen a few case studies involving lethargic, methadone overdoses that were successfully treated; however, I am not sure that this route would be appropriate to use universally. Special cases perhaps.

Of course I must admit my bias about reversal agents such as naloxone. I like to give small doses and titrate carefully for effect. I'm not sure how easily I could do that in certain patients via the nebulised route. Perhaps a consideration in certain cases, but I'm not sure it would be successful in all cases. I guess you could intubate and bag the neb in, but the whole point is to prevent intubation if possible?

Why not do an inline neb while you are bagging?