Nebulized Naloxone

[Just Steve]

Hello there. I hope you all don't mind a PA student inserting themselves in here but I do deliver patients to you all on a fairly regular basis.

 

I am wondering if anyone here has a habit of nebulizing their Narcan? I have been having some very solid success with using nebulized narcan for whom I refer to as my "nodders". The folks who are breathing 8-10 a minute, will awaken briefly to sternal rub but quickly doze off again when not stimulated. Our current protocols do not cover this deliver method so I call for medical direction each time I go down this road. I have been strongly advocating its inclusion into the protocols and am looking for some input from others who may have experience/knowledge regarding this. My perfunctory google searches have found little info other than it does get done by other agencies. The perks and perils have all been anecdotal for me so far. (perks are great, perils have been rather non existent).

 

I prefer this methodology as I am running solo in the back of an ambulance. Yes, I know we can titrate IV dose for respiratory affect but it never really seems to work as well as the theory. I give a little, wait a bit, give a little more, wait a bit, give some more....then BAM...here we go dealing with Mr/Ms Grumpy Gus.

 

There is always the question of "if they are breathing, why mess with them?" It's a fair question and I answer "when working solo, I am covering many different systems at once, in a confined amount of space and time. I don't know if they are going deeper into their stupor from just ingesting the opiate or if they are now climbing out of their deepest slumber. The "wait and see" approach isn't always the most efficient when I need to rule out several causes of decreased LOC at once."

 

With the nebulized med it is a gradual onset so they awaken slower, (but I know they are ventilating and oxygenating adequately) have less of a "stormy awakening", typically don't fight at all, don't vomit...If they do get grumpy I take the mask off and let them go back to sleep.

 

I have used atomized Narcan intra-nasally with results almost as fast and reactive as IV Narcan. I think it's great for the apneic folks or at least those folks who are really deep and not ventilating adequately.

 

So what say ye, veterans of the ED? Any input? What are the downsides in particular?

 

Steve

[FriarMedic]

90% of the time I go with IM-- even if they're in respiratory arrest or responsive to loud verbal stimuli. It's a fast method of delivery and will bring them around almost as quickly as IV delivery without the risk. If they're conscious and breathing but not answering questions then I've still gone with IM. I'm in a hospital based system and if I didn't treat an AAOx0 patient but conscious/breathing, I'd probably get written up. With that being said-- nasal narcan would prob be a great choice-- but we dont carry it. But like you stated--- i too have heard good things. As far as downsides-- I could imagine the intra-nasal wears off faster than IM or IV narcan and since it probably takes just as long to administer IM vs intra-nasal....

[Just Steve]

Being unconscious isn't always a critical event where being awake can lead them to harm themselves and others. We sedate combative patients quite a bit...why do a sudden full reversal which leads to acute withdrawal sx and make them combative? Some patients who use opiates are truly in chronic pain. By taking that pain control away, we cause their pain to return. If we can titrate the antagonist to just do enough reversal to facilitate ventilation/oxygenation but keep them relatively pain free, I feel that is better medicine. I am just trying to find out the negative aspects I may be missing.

[Eahtaz]

I prefer atomized narcan. A simple plastic atomizer, half the dose up each nostril works. No needles and its super quick.

[EMEDPA]

I prefer atomized narcan. A simple plastic atomizer, half the dose up each nostril works. No needles and its super quick.

yup, this is my preference as well using the MAD(mucosal atomizer device). also can be used for intranasal benzos for seizures.

I carry one of these in my labcoat pocket at all times. recently gave someone IN narcan in the back of a car in our parking lot and it worked like a dream.

[Just Steve]

I don't disagree with the efficacy and simplicity of intra nasal administration for the patients who are are on the critical threshold of having a hypoxic brain event. I am all about rapid intervention when needed, but I am also into the concept of subtle technique when we don't need to go full tilt. Just wondering if I am doing more harm than good when opting to nebulize the dose for the sub acute.

[EMEDPA]

IF THEY ARE BREATHING 8-10/MIN i GENERALLY LET THEM SLEEP....

HAVE HEARD OF FOLKS DOING INLINE NEBBULIZED NARCAN WITH BVM WHEN RUNNING A CODE BUT ONLY IN THAT SITUATION.(woops, sorry about caps).

[medic25]

Being unconscious isn't always a critical event where being awake can lead them to harm themselves and others. We sedate combative patients quite a bit...why do a sudden full reversal which leads to acute withdrawal sx and make them combative? Some patients who use opiates are truly in chronic pain. By taking that pain control away, we cause their pain to return. If we can titrate the antagonist to just do enough reversal to facilitate ventilation/oxygenation but keep them relatively pain free, I feel that is better medicine. I am just trying to find out the negative aspects I may be missing.

 

I totally agree; if the patient is maintaining an airway and ventilating, why reverse them and get them agitated? I've pulled medics in for QA when they gave narcan to patients who were verbal; they generally end up inducing vomiting and withdrawal, and get an angry, sick patient. If the respirations are at 8-10/min, I would be happy to just put them on nasal capnography for monitoring and let them sleep it off.

[Just Steve]

I can appreciate the "wait and see" approach, especially given some time and a couple of other tests to rule out other causes of decreased LOC. In the field though, I feel the need to rule out as many reasons for their decreased LOC possible, given the limited time and resources I have available. Granted, I can go with constricted pupils, decreased respiratory drive, the presence of signs indicating transdermal drug administration, them laying on their cooking spoon, the pantyhose wrapped around their arm, or the empty bottle of methadone by their head. But we know all opiate overdoses don't show the same way. My personal fave is the geriatric patient using a variety of transdermal pain control such as fentanyl with oxycodone or methadone prn. Pt took a fall, whacked their grape, took a brief nap (aka: passed out), trouble awakening them, then they started acting funny, nursing home calls me. They have a hx of previous cva, have IDDM, cataracts, COPD with a baseline O2 sat in the low 90's. You run down this list of things. Eventually you find out the home gave them their prn oxy or methadone about 10 minutes before the fall. The fentanyl acting in a synergistic way with the opiate, dropping their LOC into the can. If I can reverse their decreased LOC via low dose narcan but not put them back into their chronic pain, it may save them a CT scan of the melon..maybe not. I dunno.

 

When I get to them in the street I don't know if they are going deeper into their slumber as the drug has not yet hit it's half life, or if they are climbing out of it. Based on amount of opiate administered, their tolerance, method (IV vs IM vs inhalation), this time frame can vary widely. If I knew for certain that they are climbing out of it, the wait and see approach works great with an occasional reminder to them to take a deep breath or two. But if they are still going "deeper", I'd like to head that train off at the pass gently, rather than having to get super aggressive and do a full reversal.

[medic25]

I can appreciate the "wait and see" approach, especially given some time and a couple of other tests to rule out other causes of decreased LOC. In the field though, I feel the need to rule out as many reasons for their decreased LOC possible, given the limited time and resources I have available.

 

Philosophically I would question why we would need to rule out every reason possible in the field in a patient who is relatively stable. Yes, giving the narcan may give you an answer, but will it change anything regarding the patients morbidity? It took me a while as a medic to accept the fact that sometimes the right thing to do for the patient is to do nothing. Even setting aside the angry junkie woken up with narcan and using the nursing home patient, I see issues. You have an elderly person already on fentanyl and being supplemented with oxy/methadone; they are not hypoxic, ventilating well and have a stable airway. Now you administer the naloxone and they wake up in the back of your ambulance; will they have a better long term outcome? The elderly patient is generally on such potent medications for a legitimate pain issue; do you really want to be reversing an analgesic on a metastatic breast Ca patient with bone mets? I tend to be incredibly cautious about reversing narcotics in patients using them for pain rather than recreation. Unless you are contemplating the start of assisting ventilations I just don't see the benefit.

I think the concept of nebulized naloxone is certainly interesting and worth looking at, but I still have a couple of concerns. Given the lack of literature on the route, it is not well established how reliable a technique it is. It would seem to be quite dependent on the patients ventilatory drive to allow adequate uptake of medication. If a patient failed to respond to it, do you know that it is because they did not take a narcotic, or were they simply not breathing deeply enough to take in an adequate dose? At least with intranasal it is fairly well established that they will receive a sufficient amount of the medication. One caveat with IV narcan is that a lot of people forget the "titrate" concept and just slam the patient with 2mg. If a patient is stable and you're looking to gently awaken them, you can always start very low (0.4mg or even less) and repeat the dosage until you start to see efficacy.

[rcdavis]

agree with most above. no one will fault you for trying to reverse SIGNIFICANT respiratory depression or ALC with straight narcan, but a more humane method is to take an ampule and dilute it 1:10 with 10 ml saline and inject it SLOWLY IV .. watching carefully for a change in sensorium as you inject.. goal is to just get to a documented change, then STOP the naloxone.. and so doing, you avoid full blown narcotic withdrawal.. remember, once blocked, those opiod receptors cannot be overcome by simply "giving more narcotic"...