EMS Protocol of the Week - Overdose (Adult and Pediatric)

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In last year’s version of the protocols, the main place to find guidance regarding naloxone administration was in the protocol for Altered Mental Status. This year, naloxone is given its own spot to shine in a broader protocol for various types of overdose. Bear in mind as read through the protocol top down that, when indicated, patients may receive up to 4mg of naloxone IN as well as up to 4mg naloxone IV prior to arrival – important information to have when taking EMS report. Another interesting addition to this protocol for 2022 are Medical Control Options for diphenhydramine, sodium bicarbonate, and a variety of benzodiazepines – to be used for dystonic reactions, TCA overdoses, and sympathomimetic overdoses, respectively – so don’t be caught off guard if the OLMC phone rings with a request for one of those.

Cool stuff – better organization, extended spectrum of meds, what more could you want? www.nycremsco.org or the protocol to see what else we have in store!

 

Dave

POTD: Naloxone

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Today, I’ll be touching on the life-saving medication Naloxone.

Epidemiology:

In the US, there are three million people with opioid use disorder (OUD). 68K+ people died from opioid overdoses in 2020, nearly 40% higher than 2019. The deaths were primarily attributed to synthetic opioids.

Patients who have overdosed on opioids will show the classic triad of constricted pupils, decreased respiratory rates, and somnolence. You should consider naloxone administration in OUD patients with RR<8 and GCS<12.

Naloxone:

Naloxone is the antidote for opioid overdose since it is an opioid antagonist. Naloxone is available intranasally, intramuscularly, nebulized, and intravenously.

The onset of action is within 1-2 minutes, but remember that the half-life is 20-90 minutes. The half-life of the opioids are longer, so it’s recommended to observe these patients for at least 3 hours.

The first question you must ask – could this patient die from apnea? If so, you can bolus large amounts of naloxone. If the patient is somnolent but not apneic, you can titrate smaller doses at a time.

In a patient with OUD, there is a higher likelihood that you will precipitate withdrawal through the administration of naloxone. Therefore, start with lower doses of narcan for OUD patients compared to opioid-naive patients. As a side note - some of the doses below are controversial depending on the source that you’re looking at. Remember, the dosing of naloxone depends on the route.

Intranasal narcan:

  • 4mg in one nostril intranasally

  • Redose as needed

  • MMC ED Pharmacy has kits with two 4mg spray bottles

  • Available over the counter in New York

IM/IV dosing:

  • Apneic/dying patient: administer 2mg-4mg IM/IV off the bat

  • OUD patient in overdose: 0.1mg IV (0.4 mg IM) aliquots, q1-2 minutes. Consider larger doses if your patient isn’t responding appropriately. Synthetic opioids may require higher doses (sometimes up to 10mg IV.)

    • Titration: The goal is to titrate to a point of adequate ventilation and airway protection, but not necessarily full arousal. But the patient should be arousable.

  • Opioid-naive patient in overdose: 0.4mg IV/IM

Initiating a drip:

  • Because the half-life of narcan is short, you may want to consider starting a drip for patients requiring repeat doses.

  • Calculate the amount that the patient required to wake up to an appropriate level and then put them on a drip ⅔ of that per hour.

Nebulized naloxone:

  • If the drip is taking a while to set up, you can consider administering nebulized naloxone by mixing the 0.4mg vial with NS.

I would recommend having them placed on a monitor in resus with an EtCO2. If your patient develops respiratory distress, consider non-cardiogenic pulmonary edema as a side effect and get a CXR. These patients may require intubation.

EMRAP just did a piece this month about the importance of dispensing Narcan kits in the ED (as opposed to just a prescription for it, which goes largely unfilled.) This is a lifesaving medication, so I highly recommend giving a kit to every OUD patient in the ED.

https://www.emrap.org/episode/emrap20223/takehome

Last couple of pearls and tidbits:

  • Check the skin: you may find fentanyl patches which can be causing their overdose. Fentanyl patches come in doses 12mcg-100mcg/hr and require changing q72h. Just keep in mind that the effects may linger after removal.

  • Consider making push-dose naloxone. Naloxone comes in 0.4mg vials. If you mix the vial with 10cc of NS, you will be able to give 0.04mg/ml aliquots easily.

  • If there’s literally no response to the naloxone at high doses, consider alternate etiologies. Pontine stroke may be a mimic.

  • Watch the show “Dopesick” on Hulu. It follows the story of oxycodone coming to market and the Sackler family. It’s crazy.

  • You can have your own take-home Narcan kit. Just pick it up from our friendly ED pharmacists. You could save a life!

  • Also, as a reminder, Relay for Life is also an amazing service for nonfatal opioid overdoses.

References:

https://wikem.org/wiki/Naloxone

https://emcrit.org/ibcc/opioid/

https://litfl.com/naloxone/

https://www.ncbi.nlm.nih.gov/books/NBK553166/