Morphine Overdose

[medic001918]

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.

Without details in regard to the extrication from the house, the narcan shouldn't wear off prior to that being able to be accomplished in the majority of cases. If it's a complicated and prolonged extrication that would change the scenario a little bit. I'm still thinking that for most extrications, it shouldn't become an issue.

Shane

NREMT-P

[vs-eh?]

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.

I agree 100%.

Personally, I would have elected to intubate the patient as well. For the reasons AZCEP and WelshMedic initially mentioned.

Titration of naloxone (especially prehospital) can be fairly difficult (no drips) and variable with regard to patient presentation, hx of narcotic use, and response to the antagonist. Personally I would much prefer the patient WelshMedic had than a potentially agitated, combative, semi-conscious, vomiting mess.

I also would not be giving naloxone post intubation in the back of the ambulance. Traumatic extubation anyone?

[Thunderchild145]

I wouldn't try to mess with titrating prehospital. Personally (and once again I wasn't there) I would have bagged without intubation, and administered the naloxone bolus. In the 15 minute window I just bought myself where the patient is hopefully now breathing and maybe starting to wake up, I'd get him out to the truck and take him to the hospital. Due to shorter transport times here, I think were he in this area we'd have him to the ER before the naloxone wears off, but since I don't know where the rest of you are, that may be a thing that only applies to me.

So yea, to reiterate: Narcan, then more narcan, and only then tube is what I've always been told.

[Ridryder 911]

I agree that there is alternative ways on treating this scenario. Not saying one way or another is better or clear cut. Personally, I have seen many cases of accidental or even intentional overdosing, (the cause is immaterial), with such I have seen Morphine and most opioid products respond very well to Narcan and relatively usually in small doses (0.4mg-<2mg). My objective is simple though, to see if it responds and to only titrated my treatment to correspond to respiratory and maintaining them hemodynamically stable. Really, the only danger would be those two main objectives.

Even in the ED setting our treatment is conservative, and we rarely intubate if we know the cause and are able to improve the respiratory drive and LOC enough so the patient can control their airway. Continuous monitoring of course, as well we are not attempting to reverse suddenly as to cause those potential side effects of sudden withdrawal. Extubation and the problems of associated with intubation should be heavily considered before attempting. Usually, we allow the medication to wear off with time.

Again, like ERDoc discussed everyone can armchair quarterback. As well, each of us might have treated differently given the situation.

R/r 911

[WelshMedic]

I will admit that a Narcan bolus would have been prudent, but it was a text book intubation and we were able to carry out the extrication in a controlled fashion. All in all I may well do things differently next time, but I don't think this particular patient came to any real harm.

I wasn't able to check up on his status tonight as we've had a hammering tonight and didn't get back to this particular hospital.

WM

[itku2er]

Carl

When you can let me know how he is doing.

Thank

Terr

[CBEMT]

I know that in one of our hospitals, the first thing a patient gets after EMS Narcan is IM Narcan.

So yet another option is Narcan bolus to wake him up, IM Narcan to keep him going.

[scratrat]

I know this probably has little to do with the original post but....

I had a dead guy we pronounced who was in his 30's. His wife did not think it was a problem that when she left for work, he was seen EATING morphine patches. Needless to say, by the time we got there, he was long dead. We calcuated he ingested over 3000 mg of morphine.

Another case was an oxycodone overdose. We gave Narcan 2 mg. After several minutes, we inubated since she was still not breathing. She eventually woke up a bit and began fighting. At first the ER was pissed because we tubed her. Then they realized that since it was long acting, they would require a large narcan drip. I forget how much she ingested, but it was an enormous amount. So they left her on the vent for 24 hours to let nature run it's course.

[WelshMedic]

Hi Scat,

I think your contribution has a lot to do with the original post. That's the point, long-acting oral morphine is much more difficult to reverse than a "quick shot".

WM

[firefighter523]

A good practice to get into, is if you suspect a narcotic OD, to take the short amount of time (after you place the pt on high flow 02), to place the pt in a reeves stretcher, and cravat his two hands to the handles on the side of the reeves. That way, when you awaken him, he is on the 02, and secured into the reeves. He can't spit, or throw punches, you are in total control of them in most cases.