Another life saved
There had to be a crowd of more than 100 teenagers staring as the ambulance crew came into the dance club to treat an unconscious 17-year-old patient who was reported as turning blue. ˙Honestly, I swear, none of us has had anything to drink,Ó said the patient_s best friend. ˙We got here about an hour ago. Jeremy said he wasn_t feeling good, then he started getting sleepy and slumped down right here.Ó
Jeremy was clearly in trouble. The EMS crew immediately sprang into action and managed his airway by inserting an oral airway with surprisingly little resistance. As one of the EMTs ventilated Jeremy with a bag-valve mask, others helped a paramedic hook up the heart monitor, start an IV and check his blood sugar. ˙Should we drop an ET tube?Ó asked one of the providers. ˙Let_s just see if we can correct whatever the problem is first,Ó replied the team leader.
One of Jeremy_s friends said he thought Jeremy was diabetic. This could have played a role in Jeremy_s condition, but what would account for the respiratory depression? ˙Blood sugar is 108,Ó shouted one of the EMTs. ˙I_ve got an IV here. Someone hand me the tubing,Ó said another. ˙Someone check his eyes for me,Ó instructed the team leader. ˙Pinpoint and non-reactive,Ó came the reply. ˙Let_s go ahead with a couple milligrams of Narcan. If that doesn_t do anything, we_ll consider intubation and then get going,Ó said the team leader.
In less than 60 seconds following Narcan administration, Jeremy_s respirations were greater than 20, and he was starting to react to the oral airway. Not long after that, he was sitting up and talking with the crew. Jeremy_s best friend turned to the team leader and said, ˙You guys rock! You saved his life. The way he went from almost dead to talking was a miracle!Ó The team leader calmly turned and said, ˙Nah, it_s just Narcan.Ó
What Jeremy_s best friend didn_t tell the crew was that they_d been buying OxyContin at the club. This was the fourth time they_d done it. But this time it almost cost Jeremy his life.
For $20, a guy in the parking lot would sell each of them a little pill that they would crush up and swallow. The problem was that Jeremy didn_t know OxyContin comes in different doses. The dealer had been selling them 20-mg pills but accidentally gave Jeremy an 80-mg pill this timeƒfour times his previous dose and the equivalent of 16 Percocets.
Narcotic use today
Since the mid-'90s, narcotic overdoses have been on the rise throughout the country. Ambulance services that might have only seen a couple of narcotic overdoses each year in the 1980s are now seeing dozens, and in some cases hundreds, a year.„
Heroin has made quite a comeback, and drugs, such as oxycodone, hydrocodone, fentanyl and OxyContin, are commonly prescribed. As the population ages, and as medical professionals see the importance of appropriately managing a patient_s pain, drug companies are producing and selling narcotics in record numbers.
Studies show that teenagers have increased their abuse of narcotics (other than heroin) by more than 300% in the past 10 years. A 2005 study found that nearly one in five (19% or 4.5 million) teens have tried prescription medication (pain relievers such as Vicodin and OxyContin; stimulants like Ritalin and Adderall) to get high.1
A portion of this population overdoses. Narcotic overdoses are caused by a wide variety of drugs, including OxyContin and fentanyl. OxyContin produces opiate-like effects and is frequently used as a substitute for heroin. Most individuals who abuse this drug do so to gain euphoric effects. Because OxyContin is a time-release tablet, users often chew, snort or inject it to accelerate its effects and get an instant and intense high.
Another drug that has hit the streets is fentanyl. Fentanyl is cheaper than heroin and 80Ï100 times more potent than morphine, which make it an appealing drug to abuse. It can lead to respiratory failure so quickly that patients die before they even finish shooting up. Reports of people chewing or eating fentanyl patches have been surfacing for several years.
Use of heroin laced with fentanyl has grown this year in larger U.S. cities, resulting in hundreds of EMS calls. Fentanyl amplifies the potency of heroin, and the combination can kill because it severely depresses the respiratory system and central nervous system (CNS). It may not be obvious to drug users when heroin has been laced with fentanyl.
EMS crews are also being called to treat people abusing codeine, Darvocet, Tussionex, Talwin, Endocet, Norco, and the list goes on and on. It_s important that you know the symptoms of these overdoses (see Figure 1, p. 75), because your service will probably experience an increase in narcotic overdoses soon enough (if it hasn_t already).
The opiate high
In„U.S. law, the term ˙narcoticÓ refers to opium, opium derivatives, and their semisynthetic or fully synthetic substitutes, as well as cocaine. Opiates are powerful drugs that have been used for centuries to relieve pain. They_re derived from the seed of the opium poppy plant, which is appropriately nicknamed the ˙flower of joy.Ó Approximately 20 different alkaloids are derived from opiate powder, including heroin, morphine and codeine.
Other drugs, termed opioids, are synthetic drugs. These drugs aren_t derivatives of opium, but they have pharmacological properties similar to opiates. Some of the most popular and highly abused opioids for pain management include fentanyl, oxycodone and OxyContin.
Your body makes its own supply of opiates, called endorphins. As the body_s internal pain regulators, endorphins bind to opiate receptor sites, thereby blocking pain. They_re released immediately following an injury and can provide enough pain relief to allow a person to escape from a harmful situation. When the threat of danger or harm has passed, endorphin levels decrease and intense pain may return. (If endorphin levels remained high and continued to blunt the pain, a person might not take notice of an injury and fail to seek medical care.)
Endorphins have another interesting twist. If you_re one of those people who can_t resist the lure of chocolate or donuts, you_re an addict, laid low by food_s ability to produce opium-like chemical responses in the brain. When ingested, chocolate and other high-sugar foods typically trigger feelings of pleasure through a domino effect: You taste food, it sends a nerve impulse to the brain that triggers the opiate domino, and the opiate domino triggers the dopamine domino, which in turn makes you feel good. In one study, Narcan was given to subjects, and this pleasure response to foods was blocked.2 This is because Narcan is classified as an opioid antagonist, which means it_ll competitively seek out, and ultimately block, the opioid receptor sites in the CNS.
That study illustrates how opioids attach to specific proteins called ˙opioid receptors,Ó found in the brain, spinal cord and gastrointestinal tract. These opiate receptors are crucial to how the body perceives and responds to pain or pleasure. In trauma, injury or illness, specialized nerves carry a pain message to the spinal cord where it_s relayed to other neurons, some of which carry the message to the brain. When opiates bind to the receptor sites along the spinal cord, they interfere with the transmission of the pain message between neurons and prevent the pain message from reaching the brain.
Opiates also bind to receptor sites in the brain, which affect how a person experiences and perceives pain. Opiates don_t make the pain go away; they change the person_s subjective experience of pain. This explains why patients receiving morphine may say they still have pain, but that the pain just doesn_t bother them anymore.
When opiates are used by someone who_s not experiencing pain, the drugs induce euphoria by affecting regions of the brain that control pleasure. The intense rush is brief and followed by a few hours of a relaxed, content state. Many users enjoy this feeling so much, they seek to experience it repeatedly, making it an addiction. In a negative and potentially lethal side effect, opiates act directly on the respiratory center in the brainstem, which can lead to a depressed respiratory rate or loss of respiratory effort altogether, resulting in complete respiratory arrest and ultimately death. That_s where Narcan comes in.
With the changing curriculum and EMTs in some states being authorized to perform additional skills and administer a wider variety of medications, more ambulance services are carrying Narcan than ever before. But do„EMS providers use it effectively? Are some overdose cases slipping by undetected or underdosed?
The most commonly used concentrations of Narcan in the prehospital setting are 0.02 mg/mL, 0.4 mg/mL and 1 mg/mL. Many systems now allow their providers to start with 0.4 mg and increase the concentration until they reverse the effects of the narcotics, such as respiratory and CNS depression and hypotension.
Standing orders don_t typically prescribe a tailored approach to each patient_s problem when it comes to an overdose. The orders are often plain and simple: Administer Narcan 2 mg IV. If there_s no response, repeat the initial dose every two minutes, up to a total of 10 mg. But the response of your patients can be vastly different.
A good rule of thumb is to start with a small dosage and work your way up, allowing the patient to become conscious enough to breathe on their own. It_s not always beneficial to fully awaken an overdosed patient, especially one who_s a known abuser. The dose of Narcan should be individualized for the patient whenever possible.
It_s imperative to understand that Narcan doesn_t cure the overdose. It just temporarily prevents the drugs from having an effect on the body and restores enough consciousness for the patient to breathe on their ownƒpart of an organized approach to resuscitating a patient who_s suffering from an overdose.
Resuscitation occurs in a prioritized order; no aspect of care should be overlooked in favor of another. Emergency treatment must evolve from basic to advanced, and resuscitation should not be concentrated on the administration of Narcan until airway, breathing and circulation are secured.
Also keep in mind that Narcan is shorter acting than most of the drugs it reverses. Therefore, your patient may slip back into an unconscious state. You may need to administer Narcan repeatedly to get the patient through the overdose.
With the increasing number of narcotics being abused concomitantly with other drugs, Narcan may also be a diagnostic tool for the unconscious patient of unknown etiology. If there are no opioids in the patient_s system, Narcan will constrict the pupils. If the patient has opioids in their system, Narcan will cause the pupils to dilate. In the absence of narcotics, it exhibits essentially no pharmacologic activity.
Routes of administration
Narcan is supplied as an injection solution in various concentrations. In a patient with a known or suspected narcotic overdose, it should be administered via an intramuscular (IM) or intravenous (IV) route. Administering Narcan IV provides the quickest action (within one to two minutes). When administered IM, the desired effects are usually seen within two to three minutes. Narcan can also be administered via the intraosseous route in an unconscious patient and result in quick action, similar to when administered IV.
The route of administration should be individualized for the patient. In order for Narcan to work, it has to get to the receptor sites along the spinal cord and in the brain. If a patient has been down any period of time, IV access may be difficult, making IM administration seem like the faster, easier route. However, when the patient has a prolonged downtime, blood supply is shunted from the muscles, dramatically decreasing absorption of the drug. Without proper management of the ABCsƒespecially circulationƒthe IM dose of Narcan could sit in that muscle indefinitely.
Intranasal administration is gaining popularity because Narcan can be atomized, it_s absorbed easily across nasal mucosa and a needle isn_t required. Drug abusers who require Narcan therapy comprise an especially high-risk patient population due to their increased risk of carrying HIV or hepatitis B and C.
Attaching an atomization device, such as the MAD (Mucosal Atomization Device) (see photo), to the syringe instead of a needle can reduce the number of needle sticks involving this high-risk population. The atomizer is placed in the patient_s nostril and fine particle atoms of the administered drug are absorbed across the mucosal membranes. This route of administration produces the desired effects almost as rapidly as the IV route without the needle-stick risk.
Few side effects
Narcan is an extremely safe drug, with few reported side effects. However, you must still proceed with caution when using Narcan; it can provoke an acute withdrawal syndrome if the patient is addicted to narcotics. In addition, when giving Narcan to a comatose patient, take extra care to recognize and guard against aspiration, as vomiting may occur before the patient is completely alert.
Acidotic blood and tissues caused by hypoventilation or cessation of breathing for a period of time can cause non-cardiogenic pulmonary edema, in which the membranes in the lungs become porous and allow the blood serum to move from the capillary beds into the air spaces of the lungs. Repeated use of Narcan can be fatal in these patients.
Violent and aggressive behavior following Narcan administration is uncommon but possible. Behavioral outbursts are most often related to confusion, sudden awakening, immediate narcotic withdrawal or the actions of other concomitantly ingested drugs now unopposed by the narcotic effect. This is a terrifying situation for the patient, not to mention the EMS provider. Be on guard.
In a case that emergency department staff referred to as ˙the case of the fentanyl twins,Ó a 41-year-old male ended up on a ventilator after he chewed a fentanyl patch. His friend did the same thing but didn_t say a word to the EMS crew on scene. In fact, he watched as the crew intubated his near-death friend and whisked him away. Shortly after the ambulance returned to its station, a second call came in from the same address for the exact same problem. You can guess who that patient was.
More than likely, an overdose patient_s friends know what has been taken, but that doesn_t mean they_ll tell you. Even as their unresponsive buddy is being carried away on a stretcher, they may still not say anythingƒeven if they_ve ingested the same drugƒfor fear of criminal actions against them.
Many long-time ALS providers may remember that during their initial training they were told it would be rare to encounter a true narcotic overdose requiring Narcan. Many went on to find this statement to be true. But not anymore. The number of times Narcan is indicated, and more importantly, has a positive impact on the patient_s condition, has gone from once or twice a year to perhaps dozens in most EMS systems, depending on call volume and service location.
Just as a diabetic patient should never be delivered to the hospital with undetected hypoglycemia, a narcotic overdose should never be delivered undetected. How aggressively you treat an overdose patient will be driven by a variety of indicators, including level of consciousness, respiratory rate and quality, pulse ox and end-tidal readings, as well as the patient_s overall presentation.
When Narcan is administered appropriately, you might have onlookers claiming they_ve just witnessed a miracle. Of course, you_ll know it_s just Narcan.
Karen Barker, RN, CCRN, EMT-P, is a critical care registered nurse and paramedic involved in EMS since 1989. She_s a paramedic educator for Gateway Technical College in Burlington, Wis., and is affiliated with the New Berlin (Wis.) Fire Department. Contact her at„email@example.com.
Don Hunjadi, EMT-I, has been executive director of the Wisconsin EMS Association since 1992. He_s a past member of the Wisconsin EMS Advisory Board and has been a firefighter and EMT-I with the Wind Lake (Wis.) Volunteer Fire Department for more than 20 years. Contact him at„firstname.lastname@example.org.