Morphine Overdose

[AZCEP]

How about not using so much Narcan that the patient will wake up enough to need restraint?

We use just enough of the antagonist to get them breathing, but not so much to make them combative. I've also liked the limited results I've gotten with Revex (Nalmefene) and Revia (Naltrexone).

Longer lasting, and less of the sudden responses.

[FireMedic65]

ok, i didnt read everyone's post... but the general conclusion seems to be the same as mine. control the airway. I wouldn't give narcan unless after intubation (right placement of course) and the pt wasnt showing any signs of improvement, even then, only small increments. i dont know these pt's from a hill of beans. blasting them with narcan, as well all know takes away their high... and they get pissed. smaller dose.. keep em alive.

[firefighter523]

So, you are banking on being right on with the amount it will take him to maintain 10 breaths per minute. It is much easier to restrain someone who is unconcious then someone who might be fighting you, because you misjudged your titration. Believe me, it works well, especially if you have a ton of other things to worry about, ie... extracation. If he is secured to the reeves, ticked off, but breathing (high flow 02) then thats ok, at least he is secured and breathing. Wether he is mad, is not our problem.

Also you have no idea of the pharmacokinetics with each pt, ie... how much of any opiate they might have taken, you have no idea how narcan is going to work for this pt, or any. It is better to get him the full dose, in the controlled environment that you have created, then to wait around to see if .4 actually worked for him, don't you think.

[elvismedic]

From the posts I've read everyone seems to be concentrating on a push of narcan. I was taught that to prevent the patient from being combative give narcan IM that way it is slowly absorbed. The times I've given it was IM and the patient didn't become combative. Maybe I was just lucky.

[Just Plain Ruff]

when I give narcan I usually also restrain the patient that way he doesn't harm himself or others.

If the patient is known to me then I will usually not restrain them but that's on a case by case basis.

I do have several instances where the patient I gave narcan to became very combative and pissed due to my taking away their 5 dollar high but those have been few and far between.

Overall if I'm going to give Narcan I'm going to at least have the patient secured to the cot really well.

[akroeze]

Doesn't tying their hands to the stretcher count as restraint? To me that opens up legal problems.

[ERDoc]

So, what is wrong with hyperventilating the pt and then getting him out? If you oxygenate appropriately you should be able to get down a flight of stairs. It takes most people to get a tube in than it does to walk down the stairs. Get him in the ambulance and then give him the narcan. You have just saved your pt from the risks that go along with being intubated (including improper tube placement and death). In some hospitals you may have saved the pt an ICU visit and the taxpayers from paying for it.

I recently had a guy come in who OD'd on valium and had minimal respirations. Hit him with some flumazenil. The first dose didn't do much so we hit him with the second dose. He finally starts coming around just as the nurse is putting in the foley. Good morning sunshine.

[mediccjh]

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?

For once, I agree with VS!!!

First, we don't know what the scene looked like. Seemed like a cramped place. In that case, secure the airway, extricate, then treat. If I tube, I'm not giving Narcan. And if I'm giving Narcan, I'm tying down arms first to protect myself.

[WelshMedic]

Hello everybody,

I appreciate everyone's input on this subject. To comment on a few suggestions made here:

ERDoc, it wsan't one flight of stairs but three. Pre-oxygenating him wouldn't have done it, he would have been very hypoxic by the second stairwell. Intubation shouldn't be taken lightly but I think it's a little inflammatory to mention death as a result of it. I'm well aware of the consequences of misplacement. That's why we have a 5 point-check before going a step further, including EtCO2 (recognized as the gold standard when it comes to tube placement and monitoring, especially in this particularly tricky case).

Elvis, the truth is that I'm just not very experienced in using Narcan. I'm an experienced medic with 10 years service, but an opiate OD I've seen maybe once or twice. Despite Holland's reputation with regards to the coffeshops in Amsterdam and the "illegal" substances they sell, hard drugs (heroin, cocaine, crack) are just not a problem here like they are in the States. The Dutch tend to keep it to alcohol. This meant that I didn't want to overdose him and have a very pissed pt who was fighting us all the way down the stairs, plus I was genuiely concerned about the morphine kicking in again and having to start all over again.

Regards,

WM

[WendyT]

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

Oral doses of morphine is the way a friend of mine took hers, she had a long acting and a short acting regime.

She took hers because she had severe pain in the abdominal cavity area, over growth of the tissue forming from past surgeries. (being opened to much to remove much of the same).

I believe narcan wouldnt have been much help because it doesnt stay active for very long, I have read up on it to understand it's uses.

There have been days and even weeks she's gone with out, but when she started back up on it, she said it didnt do its job, and I think because she's been on it so long that it's burnt it's pain-free flame out.