It starts with the idea of the fix it, “I know this is wrong so I can fix it...”
I have been teaching this concept for the last 5 years. Narcan is a magical tool in our medication kits. It has saved countless lives. It has helped law enforcement canines and allowed many responders to go home after being exposed to deadly uncontrolled substances. But, for most patients, we may loose sight of our basic skills and instead implement a fix it. Then we can get caught with our pants down and our patient becomes hypoxic and codes on us.
ABC's is as simple as we can be. Scenario:
Called to an unresponsive 23yr old female in a upscale neighbor hood. You arrive to find a woman laying on the floor of the bathroom with a bottle of pills spread all over the floor. When you check the bottle. It says Hydrocodone 10/325. When doing a simple check on the patient she is barely breathing and she is very pale with cyanotic lips. What do you do? I'll give you a hint. Don't reach for the Narcan.
Do a rapid assessment. Check the airway, find out if the patient's breathing is adequate at all. See if there is any sign of trauma or bleeding. If done right, you may need to BVM or intubate your patient. You may need to secure your airway and suction. Remember in the initial life saving stages, the overdose isn't going to kill them, hypoxia will.
At this point you don't don't know if our 23yr old took the pills or has something else happen. Consider limiting head movement incase of trauma. After your ABCs D E and any other thing you throw in the initial assessment, start thinking 2ndary criteria. Do a SAMPLE if possible. Did you check for ID or medical alert bracelets? Have you checked a blood sugar level? I'm not trying to be tricky, just assume that even though it looks like an OD, it might not be.
Check the bottle. Find out how many pills were prescribed. Do a rapid count see if way too many are missing. See if only a few are missing. Check the expiration date. See if there is anything else around. Does the patient take other medications that might interact? Do they have a chronic disease that affects them? Do they have cancer? What if we are postictal after a seizure. Do we treat any of these things differently in the first few steps? No. ABC... 123...
Now we find a bunch of pills are missing and they were only prescribed 2 days ago. You also find a cupboard full of antidepressants and anxiety meds.
My thoughts now...
How much time has passed? If you are like me, this process takes a min or so, after I've worked on the life threats, then I become an investigator. I hunt for the answers. I go Batman on scene. Ok no, Batman is way cooler than me, and has way more money!
Now I hunt for a rapid IV start. If i don't find anything worth poking in 10 seconds, I go straight for my IO. With an unconscious unresponsive OD patient I will often hunt the bone. One of the reasons behind this, is so I know I have a site and I know I can titrate.
I also start thinking about how fast I want to wake them up. If I can wake them up.
I draw up my Narcan and run some form of fluid. My favorite approach is to spike a bag of LR and draw up 50cc's in a 60cc syringe and put it high on the line. Then I hook up my narcan near the patient. I slowly push both. This is used as an dilution method to disperse as much medication to as many receptors as possible.
My other favorite method is to draw up 2mg into a 10 cc flush and run NS and slowly push 0.2mg/1ml at a time. About every 15-30 seconds and trend my results.
I try not to wake a patient fully. I just want to overwhelm the opioid receptors long enough to get ahead of additional hypoxia. Then I will CONTINUE slow pushes to stay ahead of the OD. This should be self explanatory.
BLS - Shove the MAD device in the nose and push. Be prepared for an angry patient who's "high" has briefly ended. HAVE PD near by if need be incase restraint is needed. These events are rare but they do happen. There is a a story for a different time.
My big take away is not get wrapped up in a Narcan can fix most overdoses. Instead it’s more like Narcant fix airway, Narcant resuscitate a heart, Narcant fix meth or bath salts, Narcant fix blood sugars. Narcan should never be first.
ABC's is as simple as we can be. Scenario:
Called to an unresponsive 23yr old female in a upscale neighbor hood. You arrive to find a woman laying on the floor of the bathroom with a bottle of pills spread all over the floor. When you check the bottle. It says Hydrocodone 10/325. When doing a simple check on the patient she is barely breathing and she is very pale with cyanotic lips. What do you do? I'll give you a hint. Don't reach for the Narcan.
Do a rapid assessment. Check the airway, find out if the patient's breathing is adequate at all. See if there is any sign of trauma or bleeding. If done right, you may need to BVM or intubate your patient. You may need to secure your airway and suction. Remember in the initial life saving stages, the overdose isn't going to kill them, hypoxia will.
At this point you don't don't know if our 23yr old took the pills or has something else happen. Consider limiting head movement incase of trauma. After your ABCs D E and any other thing you throw in the initial assessment, start thinking 2ndary criteria. Do a SAMPLE if possible. Did you check for ID or medical alert bracelets? Have you checked a blood sugar level? I'm not trying to be tricky, just assume that even though it looks like an OD, it might not be.
Check the bottle. Find out how many pills were prescribed. Do a rapid count see if way too many are missing. See if only a few are missing. Check the expiration date. See if there is anything else around. Does the patient take other medications that might interact? Do they have a chronic disease that affects them? Do they have cancer? What if we are postictal after a seizure. Do we treat any of these things differently in the first few steps? No. ABC... 123...
Now we find a bunch of pills are missing and they were only prescribed 2 days ago. You also find a cupboard full of antidepressants and anxiety meds.
My thoughts now...
How much time has passed? If you are like me, this process takes a min or so, after I've worked on the life threats, then I become an investigator. I hunt for the answers. I go Batman on scene. Ok no, Batman is way cooler than me, and has way more money!
Now I hunt for a rapid IV start. If i don't find anything worth poking in 10 seconds, I go straight for my IO. With an unconscious unresponsive OD patient I will often hunt the bone. One of the reasons behind this, is so I know I have a site and I know I can titrate.
I also start thinking about how fast I want to wake them up. If I can wake them up.
I draw up my Narcan and run some form of fluid. My favorite approach is to spike a bag of LR and draw up 50cc's in a 60cc syringe and put it high on the line. Then I hook up my narcan near the patient. I slowly push both. This is used as an dilution method to disperse as much medication to as many receptors as possible.
My other favorite method is to draw up 2mg into a 10 cc flush and run NS and slowly push 0.2mg/1ml at a time. About every 15-30 seconds and trend my results.
I try not to wake a patient fully. I just want to overwhelm the opioid receptors long enough to get ahead of additional hypoxia. Then I will CONTINUE slow pushes to stay ahead of the OD. This should be self explanatory.
BLS - Shove the MAD device in the nose and push. Be prepared for an angry patient who's "high" has briefly ended. HAVE PD near by if need be incase restraint is needed. These events are rare but they do happen. There is a a story for a different time.
My big take away is not get wrapped up in a Narcan can fix most overdoses. Instead it’s more like Narcant fix airway, Narcant resuscitate a heart, Narcant fix meth or bath salts, Narcant fix blood sugars. Narcan should never be first.