Morphine Overdose

[WelshMedic]

Hi,

Just wanted to run a case past you lot to see what you think. It's real, and happened to me yesterday.

We were called to a townhouse in a rather run-down part of town. There we found a 45 jr old man who had a respiratory rate of 4. He was prescribed a slow release oral morphine preparation. This wasn't an intentional overdose, he just wasn't very compliant with his medication scheme and took it whenever he felt like. This had been developing over a number of days.

He was lying in a bedroom at the back of the house and the stairs were extremely narrow and partially blocked by a chairlift.

I decided to intubate after pre-oxygenating for a few moments, this was extremely easy as he had no gag reflex whatsoever. After a while we had the following parameters: EtCO2 4.3 kPA, Spo2 100%, ECG: sinustach 108, BP: 100/63. We strapped him to a backboard and lifted him with difficulty downstairs. The transport time was 10 minutes.

That's the background information. Now here's the dilemma: you'll have noticed that I haven't mentioned Narcan anywhere in the post. I decided not to give it for the following two reasons 1) it was a sub-chronic overdose and so even if it had been effective then I would have had the same problem again in 15 or so minutes because of Narcan's very short half-life. And 2) because I felt that waking him up and probably making him combative would increase the risk to everyone when getting him downstairs.

I just can't help wondering if I should have tried the Narcan and what the reaction would have been. At the hospital he was admitted directly to the ICU and as I was leaving they were drawing up the Narcan. I'll find out how thigs went on my nightshift tonight.

[itku2er]

He was on oral Morphine If so then the only way he could have gotten another dose was to have swallowed one is that right? Why was he on the Morphine in the first place? Well personally after His airway was secure and I had him in the back of the truck I would have probally given him the Narcan when I got in route like 2 min from the hospital. But he was breathing and alive when you got him to the hospital so you did no harm to him. It was your judgement. Keep me posted on this would like to know the out come.

Terr

[ERDoc]

But he was breathing and alive when you got him to the hospital so you did no harm to him.

Terr

Never say that when someone has been intubated. Intubation, while a very common procedure, has many pitfalls and should not be taken lightly. Giving narcan might have been a better way to go, though I'm playing Monday morning quarterback and wasn't actually there. Another option would have been to preoxygenate, get him down the stairs and then give him the narcan.

[WelshMedic]

Giving narcan might have been a better way to go

Doc,

Exactly, I did wonder that myself. The stairs really were a pain though and I didn't want him going off on me halfway down. That's why I decided to intubate BEFORE going down. I also agree that intubation shoudn't be taken lightly, but having to bag him if he'd gone off again really wasn't an option. I am glad that we use capnography though, I could monitor tube position throughout the whole difficult stair experience.

Terri,

How are you?

Thanks for your reply, maybe I should have given him the Narcan in the back of the rig. The problem is that I'm on my own (Dutch EMS in nothing like the States) and didn't really have a spare pair of hands. But I suppose I could have stopped. On balance, I don't think I did him any further harm but I mightn't necessarily do it the same way next time. I'll let you know how things go.

Carl.

[Ridryder 911]

Personally, I much rather treat the cause than the symptom. As mentioned intubation to me is much more risky than awakening the patient enough for an increased respiratory rate or even awake enough to maintain their airway. I personally have ha calls similar to this and titrated Narcan to the respiratory drive.

As you described, you do not want to increase agitation, but low dose and titration of Narcan in lieu standard initial dosages.

R/r 911

[AZCEP]

Sustained release morphine with the presentation here probably would not have responded favorably to Narcan. This patient was already feeling the effects of an unknown amount of the narcotic. Reversing it would have been exceedingly difficult/time consuming.

It may have been worth a try, if just to get his help walking down the stairs.

[WelshMedic]

My motto: "If the legs are working, they're walking"

I do tend to agree AZCEP, I felt indeed that any Narcan was going to be hit and miss in this situation. We had no idea how much he had taken and when.

WM

[ERDoc]

You can always give more narcan. Keep him alive enough to get him to the ER and we can start him on a narcan drip.

[medic001918]

I have to agree with others in the sense that I most likely wouldn't have intubated this patient. As far as attempting to get down the stairs with this patient, if you give the narcan and it's effective in reversing the effects of the overdose you should be able to get him down the stairs safely. This is a patient that I would have worked up in the house by having my partner bag them while I established an IV and gave the Narcan. If after a few minutes you have no effect at all with the proper dosing of narcan then I would consider another option (such as intubation).

Like Doc mentioned, intubation is not a benign procedure. It's a highly invasive procedure with it's own set of complications and potential problems that come with it. Rid also mentioned the idea of treating the underlying problem rather than the effects which would be great advice. I would not have intubated him and then given him the narcan when we got to the truck. This allows the opportunity for the patient to try to self extubate causing further airway trauma for no reason. That would have put the patient at risk twice (in the first placement of the tube, and now the removal) when the device was only in place for a few minutes.

As was already mentioned, the narcan dosing could have been repeated if needed to prevent him from going out again.

It's tough to say for sure how this call would have been handled without having been there ourselves. Based on the scenario described though, intubation would have been a last option after narcan.

Good luck,

Shane

NREMT-P

[AZCEP]

Given that the narcan was going to have a temporary effect, and the redosing was going to be difficult considering the movement described, wouldn't it be prudent to secure the airway and move the patient to the transporting unit, leaving the titration of the narcan to the ER in a more controlled setting?

Once the airway is secured, I'd have a hard time pushing any narcotic antagonist that I knew would wear off before the opiates did.