What would you do?

[cprted]

If it were me, I'd start with 0.2mg IV and see what the result was.

[ERDoc]

So, the pt is given 2mg IV narcan and almost immediately wakes up but is agitated, combative, diaphoretic, pupils are dilated. HR 140s, BP 178/105. She is brought to the ER with lights and sirens, hands and feet in restraints. You are now the physician in the ER. What do you do?

[paramedicmike]

Isn't the 'loading dose' of Narcan 2mg?

No. There is no loading dose for narcan. As was mentioned dosing starts at 0.4mg.

The "less than loading dose" theory sounds good, and I can see the logic in fractional dosing in this case to more closely monitor cause/effect. Is this a process that is widely used?

It's not a theory. And it should be a practice that is widely used. I'm inclined to think that's part of what the good doctor is attempting to reinforce along with his teaching points in this thread.

[scubanurse]

EKG, maybe some benzodiazepine to help with the agitation and combativeness as well as help some with the pain. Attempt to get an accurate medical history/med history, contact family members for this info if possible/needed. Remove the restraints as well.

I would do a thorough head to toe assessment and check the areas of restraints. With skin tears likely you'd want to address any open wounds quickly since the geri population can be more prone to infections.

[Just Plain Ruff]

^{So, the pt is given 2mg IV narcan and almost immediately wakes up but is agitated, combative, diaphoretic, pupils are dilated. HR 140s, BP 178/105. She is brought to the ER with lights and sirens, hands and feet in restraints. You are now the physician in the ER. What do you do?}

^{First off you are going to treat the patient appropriately like you always do Doc, and then you are going to find the EMS crew and discuss the finer points of giving narcan in low doses in the elderly. A call to their supervisor or their training director would also be appropriate.}

^{AND>>>>>>>> if you are their medical cirector you can take matters further. This sure sounds like the paramedic who likes to go big or go home.}

[island emt]

Make the EMS crew deal with the agitated puking PT for the next 4 hours??????

Then possibly hand them a days detention to relearn not to be stupid.

[paramedicmike]

So, the pt is given 2mg IV narcan and almost immediately wakes up but is agitated, combative, diaphoretic, pupils are dilated. HR 140s, BP 178/105. She is brought to the ER with lights and sirens, hands and feet in restraints. You are now the physician in the ER. What do you do?

Find the quietest most low stimuli room/corner of the ER and put her there. Undo the restraints and evaluate for patient safety (i.e. will she go berserk once untied and pose a threat to herself?). If she's safe then she can stay unrestrained. Depending on how agitated she is I'd be tempted to call for someone to sit with her.

Next will depend on the patient age and comorbidities. It'll also depend on whether or not she was accidentally double dosed. When the narcan wears off in an hour is she going to be right back where she was before EMS arrived? If she is that might not be a bad place to be. At least then you could redose with a lower dose of narcan (or start a drip), support her airway and breathing and continue to monitor her. Given methadone's half life she'd most likely have to be admitted.

And I think that's how I'd start; simply monitor her without immediate intervention. However, I think I'd have a low threshold for intervention with a benzo and potential airway management should her agitation and vitals continue to be a problem. I'd also strongly consider an antiemetic, zofran or reglan, to head off any vomiting as a result of the withdrawal.

Not that I want to start complicating the matter further by throwing more drugs into the mix...

Then I'd find the medic and ask just what in the world he was thinking.

[ERDoc]

Oh wait, it gets better. So, you attempt to control one of the worst cases of withdrawal you have ever seen with multiple small doses of morphine and ativan. You run a fine balance. Nurses are having difficulty getting peripheral access and you have a 22 in the left AC that is sketchy. The pt begins to tire and drop her sats. What do you do now for access and airway control?

[Just Plain Ruff]

Shit doc it just gets better and better doesn't it.

Well you call the best IV start nurse in the house, have her start the iv if she can, then you can consider controlling her airway, will just sitting her up and having a sitter with her to keep her awake work best?

You don't want to bag her since that will tire out the best of the people in your ER. could you put a Venturi mask on her couldn't ya? That would help her in conjunction with the sitter to keep her awake.

Or just say what the hell and intubate her and let her get over her withdrawal. But you are a good doctor and you wouldn't do that.

But by now you have probably dwelt with the medic in question and you've intubated him right?

[ERDoc]

I'm not saying this is my case. I am just relaying the facts that I know. The medic skipped out when she heard the doc complaining about the pt being in withdrawal. He never got a chance to talk to her. A blood gas was drawn and her pCO2 was 79. I forgot to mention that she was just discharged from the hospital for pneumonia and resp failure secondary to COPD. She was not intubated on that last admission and her pCO2 is normally around 50. Stimulating her does not improve her status.

Edited October 14, 2013 by ERDoc