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.