Noxalone Pilot Program

[Richard B the EMT]

Seems we've had numerous discussions on the use of Naloxone, not yet widely used in the NY Area. I just got this in, and am passing it along.

To: All Emergency Medical Services (EMS) Agencies

From:

Nassau REMAC

RE:

BLS Naloxone Administration Pilot Program

Date:

September 17, 2012

On behalf of the Regional Council, we would like to thank you for your interest in the Basic Life Support (BLS) Naloxone Administration program. Based upon the success of agencies in other states, The AIDS Institute - New York State Department of Health has approved this initiative for a selective pilot program. The goal of this program is to provide faster appropriate care to Opioid Overdose patients in our region.

This information packet will help your agency apply for participation in this program. Details of all requirements are enclosed. Please call (516) 542-0025 if you have any questions. Thank you for your time and interest in the BLS Naloxone Administration Pilot Program.

NASSAU REGIONAL EMERGENCY MEDICAL ADVISORY COMMITTEE

2201 Hempstead Turnpike, Bin 78

East Meadow, NY 11554-1859

Phone: 516-542-0025 FAX: 516-542-0049

Website: www.nassauems.org

BLS Naloxone Administration Pilot Program 2012

Table of Contents

1. 
   
   

1. 
   
   

1. 
   

Checklist for completion of BLS Naloxone Administration Program requirements

Agency Letter of Intent

Required Agency Information Sheet

Medical Advisor Statement of Agreement

Required equipment list for a Intranasal Naloxone Administration Program

Suspected Opioid Overdose Protocol for BLS Providers

AAREMS, Monroe Livingston, Mountain Lakes, REMO and Suffolk

1. 
   

BLS Administration of Naloxone to Reverse Opioid Overdose

Frequently Asked Questions

BLS Naloxone Administration Pilot Program 2012

Application Checklist

All BLS Agencies:

____ Signed Letter of Intent

____ Required Agency Information Sheet

____ Signed Statement of Agreement from Medical Director

BLS Naloxone Administration Pilot Program 2012

Agency Letter of Intent for Participation in the

BLS Naloxone Administration Pilot Program

We the members of __________________________________, hereby request

(

name of agency)

permission to participate in the REMO BLS Naloxone Administration Program.

We agree to abide by the following

:

1. 
   

All necessary equipment and IN Naloxone trained personnel will be provided on a twenty-four (24) hour per day, seven (7) days a week schedule.

2. All providers will complete the Naloxone Administration Training Material and complete the Pre & Post Survey. All survey materials are to be returned to REMO.

3. Our agency is regionally certified at the EMT-D level.

1. 
   

All agency and personnel must follow all policies, procedures and protocols set forth by the Regional Medical Advisory Committee and NY State.

5. Our agency will provide and document annual BLS Naloxone updates with

competency skill testing for all active providers.

1. 
   

Our agency agrees to participate in the Regional Quality Improvement Program. All calls in which IN Naloxone are administered must be reviewed by the agency Medical Advisor. A copy of the PCR must be sent to REMAC within 24 hours.

1. 
   

If our agency, or one of our personnel disregards these guidelines and/or

other applicable protocols, the privilege of providing pre-hospital Naloxone

treatment may be revoked or suspended by the REMAC.

1. 
   

Any changes to the Required Agency Information will be reported to REMAC within 30 business days.

The signatures below certify that the above conditions will be maintained and that we will be responsible for all aspects of participation in this Regional program.

_____________________________ _____________________________

Agency Captain/President Agency Medical Advisor BLS Naloxone Administration Pilot Program 2012

Required Agency Information (please print)

Agency Name: _________________________________ Agency Phone Number:

__________________

Agency Mailing Address: _______________________________ City: ____________ Zip___________

1. 
   
   

1. 
   

Designated representative responsible for the BLS Naloxone Administration Pilot Program:

Name: ____________________________

Daytime #: ____________________________

Email (if applicable): ____________________________

1. 
   

Agency Administrator (Captain or President):

Name: ____________________________

Daytime #: ____________________________

Email (if applicable): ____________________________

1. 
   

Agency Medical Advisor:

Name: ____________________________

Daytime #: ____________________________

Email (if applicable): ____________________________

1. 
   

Agency QI Coordinator:

Name: ____________________________

Daytime #: __________________ Email (if applicable):__________________

1. 
   

We will receive

Overdose Prevention Rescue Kitsfrom:

��

AAREMS �� Monroe Livingston �� Mountain Lakes �� REMO �� Suffolk �� Nassau

1. 
   

Naloxone will be stored in the Agency's station in the following manner:

___________________________________________________________________________________

___________________________________________________________________________________

7.

Naloxone will be carried and secured on the ambulance(s) in the following manner:

___________________________________________________________________________________

___________________________________________________________________________________

1. 
   

The following ALS agencies will be called for intercepts:

___________________________________________________________________________________

___________________________________________________________________________________

Must Be Completed By BLS Non-transporting Agencies ONLY:

9. Primary transporting ambulance service:

Name: _______________________________________________

BLS Naloxone Administration Pilot Program 2012

Medical Director Statement of Agreement

I hereby agree to serve as the Medical Director for:

______________________________________________________________________.

(

name of agency)

I understand that all patient care will be provided under my license, in accordance with NYS and REMAC regional protocols and training guidelines, except in cases of gross negligence resulting in injury or death.

Upon signing this document, I agree to

:

1. 
   

Provide and/or assist with annual Naloxone in-services/updates and training

Annually renew the Naloxone agreement with this agency

Participate in Q.I., and review all calls in which Naloxone was administered and any other calls as necessary

Provide medical leadership

Act as a resource for continuing education

Remain familiar with regional and NY State BLS protocols

If I have any questions concerning my responsibilities, I will contact REMAC.

MD signature: _________________________________________________

MD name printed: ______________________________________________

Date: ____________ MD daytime phone #: _________________________

MD address: ___________________________________________________

___________________________________________________

BLS Naloxone Administration Pilot Program 2012

Equipment List

The following minimum equipment should be carried on every BLS unit:

2

- Overdose Prevention Rescue Kits

Contents: 1- Intranasal Mucosal Atomization Device

1- Pair of gloves

1-

Prefilled syringe with:

Naloxone Hydrochloride Inj., USP

2mg per 2ml

1-

Rescue Breathing Face Shield

2-

Alcohol Prep Kits

1-

Administration Use Form

BLS Naloxone Administration Pilot Program 2012

Suspected Opioid Overdose Protocol for BLS Providers

AAREMS, Monroe Livingston, Mountain Lakes, REMO, Suffolk and Nassau

Patient must have suspected narcotic overdose AND respiratory depression. Naloxone is not given to rule out opiate use.

I. Perform initial assessment. If ventilatory status is inadequate (patient is cyanotic, altered mental

status, respiratory rate less than 10) support respirations according to Respiratory/Arrest Failure

protocol.

II. Check blood glucose (BG must be greater than 65)

III. Determine potential for narcotic overdose (at least one of the following)

a. History of overdose from bystanders

b. Paraphernalia consistent with opiate/narcotic use

c. Medical history consistent with opiate/narcotic use

d. Respiratory depression with pinpoint pupils

IF I, II and III are true THEN proceed with NALOXONE as follows:

IV. Open sealed NALOXONE container and remove one unit dose of Naloxone

a. Examine for appropriate labeling, expiration and appearance

b. Attach mucosal atomizer device (MAD) to the syringe

V. Insert MAD into LEFT nostril and inject HALF the medication

Repeat into the RIGHT nostril

VI. Continue to support ventilation as appropriate while initiating transport to closest appropriate

Facility

VII. Document vital signs every 5 minutes

VIII. If patient's respiratory rate does not increase to greater than 10 within 10 minutes of initial

Naloxone administration, repeat with second unit dose of Naloxone

Relative Exclusion Criteria: (Medical Control Option)



Cardiopulmonary Arrest



Recent seizure activity either by report or signs of recent seizure activity (oral trauma, urinary

incontinence)



Pediatric patients



Opiate use for therapeutic purposes prescribed by a physician



Evidence of nasal trauma, nasal obstruction and/or epistaxisBLS Naloxone Administration Pilot Program 2012

BLS Administration of Naloxone to Reverse Opioid Overdose

Frequently Asked Questions

1. What is the reporting or follow-up process after we administer the medication?

After you give a dose of the Naloxone please complete the brief data form that is included with each

blue packet. Your agency must restock the medication at the Regional Program Agency. This medication

will not be restocked at the hospital. When the Naloxone is restocked, they will collect a copy of the PCR

for the patient for follow up.

2. Can you use Naloxone if you don’t know what the person took?

Yes but you should be pointed towards the fact that it’s an opiate. Some thing should give you the

information that the person has an overdose that you will be able to reverse. Pin point pupils in an

unknown overdose with out breathing or with very little breathing. That would be the sign that it would

likely be an opioid overdose and someone should use the Naloxone on them.

3. Will Naloxone work for someone that is pulseless and that isn’t breathing?

An opioid overdose can cause someone to go into a cardiac arrest, but if the heart is not beating

medication in their nose isn’t going to be circulated through their body and it’s not going to help. It’s

something that might be used by paramedics or critical care techs as part of their resuscitation for the

patient but won’t help initially until they regain spontaneous circulation.

4. How much time after the overdose do you have to administer the Naloxone?

It will not work on cardiac arrest but any patient not breathing well will benefit from the Naloxone if

they took an opiate and that’s the reason so those are the patients we are going to give it to. They don’t

have to be breathing at all for the medicine to work because where it’s absorbed is on the mucosal

surface on the inside of the nose. It’s not absorbed in the lungs with them breathing it in and out.

5. Are there any situations where there may be difficulty with administration or uptake of the

medication?

Generally, there are very few problems with administering the medication or uptake of the medication

by the nasal mucosa. Here are some possible problems to be aware of:

Drugs like cocaine which are vasoconstrictors can prevent absorption.

Bloody nose, nasal congestion, mucous discharge – will decrease effectiveness of nasal

medication

Lack of nasal mucosa as a result of surgery, injury or cocaine abuse may also decrease

absorption through nose.

If given more medication than 1 ml or more per nostril, it’s likely to run off.

6. Does it matter if a person overdosed on a prescription drug as opposed to a street drug such as Heroin?

It doesn’t. Both prescription and non

‐prescription opiate medications will be reversed by Naloxone.

Some of these medications will require more Naloxone than others but it will work. Common street

drugs like Heroin will be reversed by this. Common prescription medications like MS Contin, Vicodin,

Lortab, Percocet, Oxycodone, and other opioid medications will be reversed by Naloxone as well.

7. Can we use this medication to determine what they did take?

If somebody is altered, don’t give them this medicine. If they are hypo

‐ventilatory, and not breathing

well enough, then they can get the Naloxone. Nalooxone is not for trying to figure out what they took

but trying to start them breathing by reversing the opioid they have on board.

8. Would this work on somebody who’s consumed a Fentanyl Patch?

Absolutely. It will work on someone that took Fentanyl or took a Fentanyl Patch. The Fentanyl Patches

have an incredible amount of medication in them. It’s a long acting medication that is designed for

application over 3 days. If someone consumes a Fentanyl Patch, they may have a little bit of resolution

BLS Naloxone Administration Pilot Program 2012

with their symptoms with their initial dose of Naloxone, but they may need more. So it’s definitely a

patient who if you have the ability to get more Naloxone to the scene, into the patient or meet other

crews enroute to the hospital who can give you more Naloxone, it’s definitely a patient who needs it.

9. What if we give the Naloxone to someone who doesn’t need it?

If there isn’t an opioid on board for that patient, there will be no effect from the Naloxone.

10. Can you give the medication is the patient is seizing?

If the patient is actively seizing it is unlikely that they will be overdosing on an opioid medication.

However, if they are not breathing and they begin to tremor, it may be because of hypoxia. If there are

any questions, contact a medical control physician.

11. Do you have to call a doctor before administering the medication?

No. With this project, there is a standing order that allows EMT

‐B to administer the medication.

12. How long before administering another dose?

If there is no response, or limited response, you may give another dose in 10 minutes.

13. Can the medication be applied sublingually if there is no access to the nose due to injury or other issue?

No. The nature of the lining of the mouth is different than the nasal mucosa. Naloxone must be

administered via the nose.

14. Is the medication temperature sensitive?

Yes, but not terribly so. This medication can be safely stored with your Epipen.

15. Is there CME credit available for this training program?

Yes, 1.5 CME Credits are available for the completion of training. Training course rosters should be submitted to REMO and CME Certificates shall be issued.

[Arctickat]

Very cool. The advent of the less invasive IN delivery systems has opened up a whole wealth of potential medications.

Have you taken the training program yet?

[ERDoc]

Rich, SCPD is also doing a pilot program with sector cars carrying IN narcan with several saves so far.

[Kiwiology]

Interesting that it is not indicated for opiates prescribed by a Physician (those dang physicians and there prescribing, can't they just be happy using that thing they carry aound their neck and sending people a bill?) ... does Nana whos back pain is abit worse today so scoffed down too much oromorph not need some naloxone?

I am torn about the usefulness of naloxone TBH, espeically in somebody who has an unknown or prolonged down time and might have a tinge of blue noggin so we go waking them up probably not the best idea ...

Also interesting that they decided to trial naloxone and not something far more useful like GTN, salbutamol or some form of non narcotic analgesia.

Gosh I am just so much fun to be around aren't I?

Excuse me, I am late for my lunch date with Buzz Killington ... I have to use my gift card for Hooters and that Consultant Emergency Physician never showed up ...

Edited September 27, 2012 by Kiwiology

[island emt]

It is much more useful in areas with a high incidence of opioid abuse. these can include heroin or prescription derivatives or synthetic opoids.

A few years ago there was rampant street abuse of the OXY family of prescription drugs. We were using a lot of narcan on a regular basis.

Then the street availability of heroin became easy & cheap.

Had an arrest call this year that was of unknown cause: 30 something just collapsed while eating a bagel. on arrival agonal resp and weak thready barely palpable carotid pulse @ 25 . cpr had been attempted prior to our arrival at the dock where pt was on a fishing boat

.

Only info we got from family present was asthma and allergic reaction to some kind of seeds.

Worked CPR, ventilations with bvm showed irreg brady rythym on monitor. Every time compressions were stopped the pulse dropped off . Breathing was 3-4 & shallow.

IV , epi given thinking anaphalaxis due to history given by family.

While enroute to hospital nothing seemed to make sense as to the WHY.

checked for track marks. checked pockets for drugs or evidence of pharaphenalia . nothing found

Blood glucose normal .

On a WAG we gave Narcan.

two minutes later eyes opened , breathing normal @ 12-14, pulse irreg @ 60. confused as hell and still working off the prolonged effects of hypoxia.

Come to find out pt had been spreading fentanyl patch gel on his bagel and having a really good breakfast snack.

It never fails to amaze me the extent that some will go to to get high. Where he got the patches from remains a mystery.

When in doubt give vitamin "N"

One word of advice to those new to it. Don't give the max allowed dose at the beginning. titrate the effect to keep them breathing on their own and try not to completely reverse the high. Nothing worse than a wide awake addict who you just ruined their high. they tend to get violent or turn on the power chum machine. neither of which are good in the back of the bus.

Edited September 27, 2012 by island emt

[DwayneEMTP]

(Note: Posting at the same time as Island, redundancy is accidental.)

This protocol seems to assume the the B's in this area are also able to do BGLs?

I'm mixed on this....but the one thing that struck me is that there is only one indicated dose, the full 2mgs. Half in each nostril...

I've only used 2mgs in one shot once, and that's when an attempted suicide OD went into resp arrest just as we walked in so I jammed it up her nose and pulled the trigger. She woke up kind, but in really bad discomfort and really agitated...I've not seen those symptoms when I titrate. She'd had enough problems already, I'd really have rather brought her up more slowly...

Do you think that it's an all or nothing because it's a basic skill?

[island emt]

I'm guessing that their thinking is in emergency situations it's better to get them breathing on their own" NOW" , & worry about the after effects when they get to the hospital.

Without an understanding of the physiology behind opioid abuse then nasal narcan is a quick easy fix that even a layperson can try.

If it doesn't work then they have to go back to the cookbook for arrest situations.

Another assumption is that they are having a severe increase in opiate OD's that could be potentially reversed by first responders.

[DFIB]

Rich, SCPD is also doing a pilot program with sector cars carrying IN narcan with several saves so far.

Doc,

This is a very different question and not an attempt to derail but have you heard of any success in using narcan as a Labetalol antagonist for persons that would benefit from Epi, such as asthmatics and cardiac patients?

[Kiwiology]

1.6 mg intranasally here in Kiwi in 2 divided doses (1/2 each nostrial)

I still think there are far more useful things they could be teaching their people .... but eh w/e

Edited September 27, 2012 by Kiwiology

[Arctickat]

Gotta start somewhere buddy, baby steps.