Unknown Overdose......possibly

[medic32]

Called to a paramedic intercept for an 84 y/o female pt who is unresponsive following an OD. Met the neighboring ambulance enroute and found the pt with a GCS of 4. The 2 EMT I's in the back of the truck said they were fine and I was not needed and I could return to the fire station. Before I left I told them I would like to take a look (trying to be nice). Much to my surprise I found that the pt had and oral airway stuck in and was on an NRB, with a RR of 4. ( I'm as shocked as you guys, WTF happened to bagging) Anyway I tried to gather somewhat of a hx from the crew that had been with this woman prior to my arrival. The story is that her care taker found her unresponsive with an open box of pills near her bed that were unlabeled. She has no hx of suicide or other psych issues. Pt is ice cold and sweaty to the touch, with the oral airway and NRB in her mouth (lol) via initial crew her oxysat was 92 with a RR of 4, with the removal of the airway her oxysat quickly dropped to 80%. Breathing is labored and irregular, BGL is 159, pupils constriced but equal. Needless to say I intubated the pt due to her compromised airway and gave 0.4mg of narcan IV. Her puplis dilated slightly to 5mm following the narcan, however no other changes were noted. I stopped with the Narcan following the initial 0.4 due to the unknown subtance(s), if any. She continued to be ventilated via ET tube and BVM with good entidal, and oxysat
and was delivered to the ED. Other than a severe narcotic OD any other Ideas what this may be. All other vital signs: BP 126/66, HR 68.

[AmbuBadger]

I'm thinking barbiturates or narcotics... mostly the latter due to the pupils and cold, clammy skin. I bet if you gave the full two migs of Narcan, you would have gotten a response! I have yet to see someone react negatively to Narcan, but supposedly higher doses can cause the pt to have sz, severe HTN, and even go into VF/VT.

I guess anything could present with almost any s/sx, especially if they were mixed. I don't know about your system, but I think I could have gotten away with pushing more Narcan with the pupil response as my justification. By the way, they just changed our S.O. dose increments from .04 to .05-- which is what everyone was doing on the road anyways... funny how that works.

[brandon911]

I had a pt present almost exactly the same way a couple weeks ago. 86 yof from a nursing home. Nursing home stated she took an unknown amount of vicodin. Pupils constricted, respiratory rate of 5-6, cool, clammy, hr 44. Oral airway, bvm. I started a line, gave 2 of narcan. No change. Gave 2 more. No change. Gave 2 more. No change. The line was good. I intubated her and she got admitted to the hospital for severe narcotic overdose. Sometimes narcan doesn't work. She tested positive for narcotics and nothing else.

brandon911

[medic3]

If you suspected a narcotic overdose, why did you intubate the patient before narcan? It seems that once you decided to intubate, giving narcan after the fact would probably cause more problems than it would fix.

[WTFOVER]

Uh... A,B,C's maybe?

[medic3]

Yeah, I get the A,B,C, thing, its just that narcan would probably be better given before moving to endotracheal intubation. If you administer narcan and the patients LOC and respiratory effort improve, there would be no need to intubate.

[Medic_QT]

Agreed.. If the patient isn't vomiting or having secretions etc, why tube them without exhausting other means? Intubation is pretty invasive. I'm a pretty aggressive medic and I wouldn't have tubed her-- just an oral airway and BVM until I'm maxed w/ narcan. I don't know, maybe medic32's protocol says 0.4mg is all they can give. We've had patients nearly extubate themselves on arrival at the ER when given narcan. I would have given a full 4mg (per my protocol) in increments of 0.4mg, or until she started to come around or her resp. depression reverses. If that didn't do anything, then yes, tube away. Since her pupils did change, I would have continued w/ the narcan route.

[FF/EMTP1317]

I'm thinking barbiturates or narcotics... mostly the latter due to the pupils and cold, clammy skin. I bet if you gave the full two migs of Narcan, you would have gotten a response! I have yet to see someone react negatively to Narcan, but supposedly higher doses can cause the pt to have sz, severe HTN, and even go into VF/VT.


I've had pt's with a rr of about 2 so they got the full dose of Narcan and subsuquently had some pretty nasty siezures.


If you suspected a narcotic overdose, why did you intubate the patient before narcan? It seems that once you decided to intubate, giving narcan after the fact would probably cause more problems than it would fix.

If I'm giving Narcan I prefer to bag them first b/c if the Narcan does it's job the pt is not going to be very compliant with the tube.

[pdxmedic]

If I'm giving Narcan I prefer to bag them first b/c if the Narcan does it's job the pt is not going to be very compliant with the tube.

Like the pt we had locally a while back who was intubated and then given narcan IV ... sat up, ripped the (inflated) tube right out, and asked the EMS crew what the eff they were doing ...

Seriously, though, bag 'em with an OPA, and get at least 2mg of narcan onboard, especially with consistent hx/findings (track marks, pinpoint pupils, drug house, old person on narcotics, etc etc etc). It's just not worth the crap you'll get from the ED for intubating someone that they can reverse with a little narcan.

The one who remains obtunded after 6 of narcan is a whole diff'rent bunny.

[medic3]

Agreed. If they don't improve after narcan, and there isn't another easily correctible cause i.e. hypoglycemia then intubate away. Once they are tubed, giving narcan is asking for trouble.

[screaming pizza]

Wow. I am seriously in a bad mood. I had written something snotty to the effect of armchair paramedic-ing (is that even a word?) but even I got offended, so I deleted it. Anyways, back to the exchange of opinions and ignore the attempted highjacking.





I either need to get drunk, or get laid or both or something. I think I'll just go beat up one of those pretentious squirrels in the backyard...stupid rodents with freakishly big feet...

[medic3]

Not trying to armchair quarterback, just making an observation. I assume the OP posted this case to generate discussion, if that wasn't the case, then I appologize.

[cwl3gemt]

ok, from a lowly basic's point of view...

seriously, what in the heck were they thinking not assisting with ventlations? I can understand the OPA, but a NRB? Im sorry, but RR of 4 aint good enough for me. I would seriously be thinking combitube at least till the paramedic shows up. they said they had it under control, but what about when they get to the ER and shes gorked out and not breathing? Im sorry, but thats bullcrap.

as for what you did, I myself dont see any issues with what you did.

[medic32]

Hey Guys,

Excellent discussion so far. As for our pt she was admitted to ICU still intubated, the medical director will get back to me on the final outcome. My thought was ABC's, the ED doc was happy with intubation and did an E-wall lavage(sp). I personally would much rather protect the airway than take chances with huge doses of Narcan. It's hard for me to explain how bad she looked. She was clearly hypoxic, very obese and very difficult to ventilate.

[AmbuBadger]

Hey Guys,

Excellent discussion so far. As for our pt she was admitted to ICU still intubated, the medical director will get back to me on the final outcome. My thought was ABC's, the ED doc was happy with intubation and did an E-wall lavage(sp). I personally would much rather protect the airway than take chances with huge doses of Narcan. It's hard for me to explain how bad she looked. She was clearly hypoxic, very obese and very difficult to ventilate.

As long as you aren't catching hell for it, it's all good. A lot of us can sit here and armchair-quarterback the whole call, but as we all know so very well, things are different when you're at the scene. Dumping the full two migs of Narcan at once would have been a no-no (there's still people out here who say, "just run that dopamine wide until we get a pressure..."), and I'm sure that if she looked like she needed a tube, you were justified. I was thinking about your post today while we were at a 90 yo diabetic-- she could have easily taken a tube, but she didn't have that "look" that we see at codes. Popped a line in her, gave the dex, took her in. NRM at 15 was good enough.

If yours were a test scenario, a lot of us would have gone the whole "check glucose, give narcan" route, but then again, I've seen a lot of guys who do great on tests end up making mistakes out in the field because they don't have the call volume & experience that let's them handle a situation like that without deferring back to "test mode". I'm confident you did the right thing, evidenced by the fact you're here asking opinions instead of telling everyone at work, "I got my 534th tube this month, y'all got some catching up to do"...

To paraphrase the knight in "Indiana Jones and the Last Crusade", "Are you tubing this pt for his glory or yours?"
http://images3.wikia.nocookie.net/indianajones/images/thumb/6/67/Knight.jpg/250px-Knight.jpg

[medic32]

Well here is the update so far, the lavage found what the Doc's note stated possibly some white fragment but not really that much, but I guess that would depend on if or when she ingested anything. Also, her triponing was bumped and had a NSTEMI. Apparently the crew never learned how long she was really down, but it was assumed the MI was caused by hypoxia and a long down time before intubation. She was extubated 48 hours later and is stable on the ICU floor recovering from a suspected benzo/opiate overdose and MI.

[CornholioMedic]

What we see a lot of is the Heroin/Fentanyl O.D.'s...not nearly as many as we used to, but with these patients, you will see many of the same symptoms associated with what you saw with this elderly woman.

Possibly Morphine/Fentanyl O.D.? Something else you COULD see in these types of overdoses are Pulmonary Hypertension. They will get the initial dose of Narcan and almost immediately post med, will develop Pulmonary Htn. I've seen it happen a few times with this type of O.D....just something else to be aware of and consider.

[CornholioMedic]

Agreed.. If the patient isn't vomiting or having secretions etc, why tube them without exhausting other means? Intubation is pretty invasive. I'm a pretty aggressive medic and I wouldn't have tubed her-- just an oral airway and BVM until I'm maxed w/ narcan. I don't know, maybe medic32's protocol says 0.4mg is all they can give. We've had patients nearly extubate themselves on arrival at the ER when given narcan. I would have given a full 4mg (per my protocol) in increments of 0.4mg, or until she started to come around or her resp. depression reverses. If that didn't do anything, then yes, tube away. Since her pupils did change, I would have continued w/ the narcan route.

Many protocols call for the following: GCS of less than 8....intubate. With a GCS of 4 and a respiratory rate of 4, I think most others would have intubated as well...especially considering this patients age. Not trying to rip on ya, but with the description he gave, I would have more than likely done the same as he did.

[medicnparadise]

our protocols for narcan say we can max dose to 10 mgs. To me, that is a friggin LOT of narcan. We have some cowboy medics who give 2 mgs as a starting dose to ANY ALOC pt they get. To me, that is wrong and you are asking for trouble. Our medic program actually teaches that there are no adverse affects for narcan. I have seen it cause seizures, DT's, and other nasty things.

That being said, I have also found that the synthetic narcotics (phentanyl, oxy) take more narcan to reverse the effects than the natural ones, like Morphine. I guess it's harder for narcan to bump the narcotic off of the receptor site. (per my medical director)

[screaming pizza]

To paraphrase the knight in "Indiana Jones and the Last Crusade", "Are you tubing this pt for his glory or yours?"

Awesome!! I wish this was realized by more cowboys.

[Medic_QT]

our protocols for narcan say we can max dose to 10 mgs. To me, that is a friggin LOT of narcan. We have some cowboy medics who give 2 mgs as a starting dose to ANY ALOC pt they get. To me, that is wrong and you are asking for trouble. Our medic program actually teaches that there are no adverse affects for narcan. I have seen it cause seizures, DT's, and other nasty things.

That being said, I have also found that the synthetic narcotics (phentanyl, oxy) take more narcan to reverse the effects than the natural ones, like Morphine. I guess it's harder for narcan to bump the narcotic off of the receptor site. (per my medical director)

Then again, we were told to do it at 0.4 increments only til they start breathing on their own again. I figured that yes, if you give it to a junkie and you bring them all the way out of it, you can cause severe withdrawl sx, ranging from extreme pain to Sz, even though in my medic school, no one taught us that.

[lerue]

We go for 0.4mics increments here, I have also bagged if resps not adequate have not tubed any, but then pt usually comes up pretty quickly, I think if narcan is not working and the job is protracted and airway management is becoming problematical, then it is a good indication to tube. I guess you gotta be there.

[firemedirk]

I guess you gotta be there.

I will say that this is the quote of the day.
We have all experienced the apathy that Brother Medic32 experienced when he entered the transport truck. I can think of many runs where the patient would have been much better of in our truck than theirs (plus I know where stuff is on mine when I am up to my arm pits in alligators......THEY BITE!). I think a good job was done in the best interest of the patient and no one got hurt. Unless of course you had to bitch slap the crew in order to make then see the light.:boxing:

[ltfd596]

Many protocols call for the following: GCS of less than 8....intubate. With a GCS of 4 and a respiratory rate of 4, I think most others would have intubated as well...especially considering this patients age. Not trying to rip on ya, but with the description he gave, I would have more than likely done the same as he did.

Agreed..... While we all agree there is no such thing as a text book call, we have all made decisions in the back of the car that other may criticize... but it is easier to have your glorified opinion when you were not there.

I just now realized that the above sentence doesn;t make too much sense, but I am tired, hungry, and haven;t slept in my own bed in 3 days.



On a side note... is there anybody else who is having a rash of bee sting lately? We ran 7 of them yesterday with 3 being severe..... the one lady seized 5 times... even after self epi, versed, valium, benadryl, solumedrol.