SAN JOAQUIN COUNTY EMERGENCY MEDICAL SERVICES AGENCY Course Curriculum Disclaimer: Authorization - EMT Optional Skills Only authorized Emergency Medical Technicians (EMT) who are on duty with a provider that has been authorized by the San Joaquin County EMS Agency may utilize EMT Optional Skills. Administration of Naloxone for Opiate Overdose 200-240 Minutes Instructor Qualifications Be qualified by education and experience with at least forty (40) hours of documented teaching methodology instruction in areas related to methods, materials, and evaluation of instruction and shall meet the following qualifications: (1) Be a Physician, Registered Nurse, Physician Assistant, or Paramedic currently licensed in California; or, (2) Be an Advanced EMT or EMT who is currently certified in California; or (3) Have at least two (2) years of academic or clinical experience in the practice of emergency medicine or prehospital care in the last five () years. The training programs shall assure that no more than ten (10) students/participants are assigned to one (1) principal instructor/teaching assistant during skills practice/laboratory sessions. Course Equipment PowerPoint Presentation Computer and Projector with Audio resources Handouts (Naloxone Intranasal (IN) Skills Competency Verification Form, PowerPoint presentation printout, Course Outline, LMA MAD User Guide, related EMS Policies) Gloves Naloxone 2 mg (vial adapter/preload syringe) as sample Water (for use when practicing administration) MAD Nasal Device Simulated patient Sharps container Page 1 of 10 09/2017
Minutes Content Outline Master Teaching Notes I. Introduction, schedule, disclaimer, course objective. Engage the audience with selfintroductions. The participant should be able to identify the need for use of naloxone by intranasal administration for suspected opiate overdose. They should be able to: Review the course schedule. 10 II. 1. List the common cause of suspected opiate overdose; 2. Cite the signs and symptoms; 3. Describe the need for personal protective equipment and scene safety; 4. Demonstrate the ability to implement the following policies: a. SJCEMSA Policy No. 03, BLS Routine Medical Care b. SJCEMSA Policy No. 04, BLS Patient Assessment Primary Survey c. SJCEMSA Policy No. 0, BLS Patient Assessment Secondary Survey d. SJCEMSA Policy No. 20, BLS Respiratory Distress e. SJCEMSA Policy No. 42, BLS Poisoning and Overdose. Define the indications, contraindications, side/adverse effects, dosages, mechanisms of drug action; 6. Administer naloxone by intranasal spray and dispose of contaminated items and sharps; 7. List the steps for providing on-going care of the patient until ALS transport arrives; 8. Demonstrate the ability to perform patient transfer of care to the arriving transport paramedic; 9. Demonstrate the ability to clearly document use on the patient care report (PCR). Medical Control Philosophy, medical control 1. Online medical control is that medical direction provided to the prehospital care team while in direct voice contact with an MICN or Base Hospital physician at a designated San Joaquin Base Hospital. 2. Offline medical control is that medical direction provided when the prehospital care team is not directly involved in patient care, via policies, and medical record audits. San Joaquin County operates primarily on a standing orders system. Confirm they understand the course objectives and are familiar with the Disclaimer. Although all EMTs needs this course to maintain their EMT certification, they might not be authorized to use it. Refer them to the EMS Agency if they have questions about maintaining their EMT certification. Dr. Buys Medical Control Philosophy. Describe online verses offline and the importance of knowing the difference. Mention standing order for Naloxone are under EMS Policy No. 42 Page 2 of 10 09/2017
Repeat the disclaimer. Once an SJCEMSA accredited paramedic arrives on scene, that paramedic will provide all further ALS Patient care. No EMT Optional Skills will be performed or authorized in the presence of an SJCEMSA accredited paramedic. III. Definitions of Opiate and Naloxone 1. Opiates are a group of drugs that are used for treating pain. They are derived from opium which comes from the poppy plant. Opiates go by a variety of names including opiates, opioids, and narcotics. The term opiates is sometimes used for close relatives of opium such as codeine, morphine and heroin, while the term opioids is used for the entire class of drugs including synthetic opiates such as vicodin, but the most commonly used term is opiates. 2. Naloxone, an opioid antagonist, prevents or reverses the effects of opioids including respiratory depression, sedation and hypotension. The effects of naloxone last about 30-60 minutes. Multiple doses may be required as the duration of action of most opioids is greater than that of naloxone. Highlight that Naloxone is not effective against respiratory depression due to non-opioid drugs. IV. Common causes of opiate overdoses Taking too many opioids can occur if: 1. Accidental overdose 2. Mix opioids together 3. Combining opioids with alcohol or sedative medication 4. Abuse the drugs (take them without a prescription or for long periods of time) Due to their effect on the part of the brain which regulates breathing, opioids in high doses can cause respiratory depression and death. Review that overdoses can happen to anyone. Certain risk factors can lead to opioid overdose. For example, elderly patients may forget that they have already taken their medication and accidently take another dose. Changes in a person s metabolism can affect the way that a medication is Page 3 of 10 09/2017
absorbed. Those with a metabolic disorder must be closely monitored while taking prescription pain medication. Prescription drug abuse is becoming more common among American youth. According to the National Institute on Drug Abuse, up to 10% of high school students abuse opioids every year. V. Respiratory Rates The normal respiratory rate of adults is 12-20 per minute. Hypoventilation is a respiratory rate of less than 10 times per minute. Hyperventilation is a respiratory rate of greater than 30 times per minute. Review when assessing a patient s ventilatory status, always evaluate the rate, rhythm (abnormal pattern, shallow), effort (labored), lung sounds (wheezing, stridor), cough, fever, spitting/coughing blood or pink froth, or barking. VI. Common Opioids 1. Vicodin 2. OxyContin (Oxycodone) 3. Codeine 4. Methadone. Morphine 6. Heroin 7. Fentanyl Review opioid patches and different ways opioids can be delivered or prescribed. VII. Signs & Symptoms The severity of symptoms varies based on the amount of the opioid taken. Symptoms of Naloxone is administered for respiratory depression or apnea. If the patient is under the Page 4 of 10 09/2017
20 opioid overdose include: VIII. Altered level of consciousness Respiratory depression Apnea (absent breathing) Pinpoint (constricted) pupils Changes in heart rate PPE, Scene Safety, EMS Policies 1. SJCEMSA Policy No. 03, BLS Routine Medical Care 2. SJCEMSA Policy No. 04, BLS Patient Assessment Primary Survey 3. SJCEMSA Policy No. 0, BLS Patient Assessment Secondary Survey 4. SJCEMSA Policy No. 20, BLS Respiratory Distress. SJCEMSA Policy No. 42, BLS Poisoning and Overdose influence of opioids, but breathing adequately, naloxone is not indicated. The patient must be monitored closely for respiratory depression or apnea. Repeat Naloxone is not effective against respiratory depression due to non-opioid drugs. Wear personal protective equipment (PPE) and ensure scene safety for both the medical responders and the patient. Whenever on an EMS call, always have a heightened sense of situational awareness to ensure responder and patient safety. When a narcotic overdose occurs, it can be from IV drug use or from medication taken in pill format. Be aware of the potential risks and challenges associated with each environment. IX. Profile of Naloxone Medication Name Generic: Naloxone Trade: Narcan Delivery system: Mucosal Atomization Device (MAD) Page of 10 09/2017
X. Indications for naloxone administration History of opioid use or a high index of suspicion of opioid use Respiratory depression Altered level of consciousness Ask if the participants have any questions. 10 XI. Differential diagnosis Definition: The process of differentiating between two or more conditions that share similar signs or symptoms. Hypoglycemia (low blood sugar) Sepsis Bradycardia (slow heart rate) Cardiac arrest Review symptoms of the potential diagnosis and the process to determine if it might be an opioid overdose. XII. Contraindications & Relative Contraindications Contraindications - None in a life-threatening situation Relative contraindications Hypersensitivity XIII. Side/adverse effects Naloxone may precipitate withdrawal in patients receiving opioids. The severity and duration of the withdrawal syndrome are related to the dose of naloxone and to the degree and type of opioid dependence. Withdrawal is characterized by: Agitation Nausea Vomiting Sweating Tachycardia Dyspnea Pulmonary edema Abdominal cramps Diarrhea Cardiac arrest Review that some of these side/adverse effects may happen quickly as Naloxone acts quickly. Page 6 of 10 09/2017
Increased blood pressure Tremulousness Ventricular fibrillation XIV. Routes of administration Intranasal spray via the Mucosal Atomization Device (MAD). Review that IN is the only route approved for EMT use. Repeat the disclaimer. The nasal cavity possesses a dense vascular network providing a direct route into the blood stream for medication that easily cross mucous membranes. This direct route avoids gastrointestinal destruction and hepatic first pass metabolism of these medications, effectively increasing their bioavailability, which is the fraction of administered drug that reaches the target tissue. The rates of absorption and time to peak plasma concentrations are comparable to IV administration, and are generally superior to subcutaneous or intramuscular routes. XV. Dosages Adult: 2mg 1mg each nostril intranasal (IN) May repeat once for total max dose 4mg Pediatric: 0.1mg/kg intranasal (IN) (half dose in each nostril) Max total dose is 2mg - Pediatric patients shall be administered only one (1) dose of Naloxone XVI. Mechanisms of medication action Opioid antagonist; prevents or reverses effects of opioids, including respiratory depression, sedation, and hypotension, by competing for the mu, kappa, and sigma opiate receptor sites in the CNS, with the greatest affinity for the mu receptor. The effects of naloxone last about 30-4 minutes. Multiple doses may be required as the duration of action of most opioids is greater than that of naloxone. Highlight to the participants: A pediatric patient is 14 years or younger. Review dosing chart for pediatric patients. Note again that pediatric patients shall be administered only one (1) dose of Naloxone. XVII. Aseptic technique Stress the importance of the use Page 7 of 10 09/2017
Definition: A procedure used by medical staff to prevent the spread of infection. The goal is to reach asepsis, which means an environment that is free of harmful microorganisms. XVIII. Prior to medication administration ALWAYS ask the patient if they have any allergies to medications. If possible, remove the source of the opiate. Examples would be removing transdermal opioid patches (morphine, fentanyl) from the patient s skin, or removing a suspected heroin needle from a patient s arm. Note - Removing the source of the opiate does not include inducing the patient to vomit. Syrup of Ipecac Commonly referred to as ipecac, is a medication that was once used to induce vomiting. It is obtained from the dried rhizome and roots of Carapichea Ipecacuanha from which it derives its name. Current literature concludes that vomiting alone does not reliably remove poisons from the stomach. of proper PPE and sterile techniques when administering medication to a patient, in order to ensure asepsis. Highlight the importance of always asking if they have allergies to medication. Ipecac will not reverse the overdose effects of opioids used in pill or liquid form such as Vicodin, oxycodone, codeine. 1 XIX. List the steps for administering naloxone by the mucosal atomization device (MAD) 1. Take universal body/substance isolation precautions. 2. Perform scene size-up. 3. Perform primary survey. 4. Provide supplemental oxygen or respiratory support as needed.. Remove any transdermal opioid patches or hypodermic needles. 6. State the indications for the administration of naloxone. 7. Ask the patient if they are allergic to any medications. 8. Check for correct medication, concentration, integrity of container, dosage and expiration date. 9. Remove the syringe from the vial adapter. 10. Attach the MAD Nasal Device to the syringe via the luer lock connector. 11. Use the free hand to hold the occiput of the head stable, places the tip of the Review all the steps in order. Have the participants review the Naloxone Intranasal (IN) Skills Competency Verification Form. Page 8 of 10 09/2017
MAD snugly against the nostril aiming slightly up and outward (toward the top to the ear). 12. Rapidly depress the syringe plunger to administer 1mg of medication into the first nostril. 13. Reposition and repeat steps 11 & 12, administering the remaining 1mg of medication into the second nostril. 14. Dispose of the syringe and MAD in sharps container. 1. Continue monitoring of patient and observing for improvement or worsening of the patient s respiratory distress. 16. Complete the secondary survey. 17. State indications for repeating naloxone administration. 1 XX. Disposal of contaminated items and sharps Sharps disposal containers should be of sufficient thickness or construction design to be durable, leak resistant, and puncture resistant under normal use and stresses imposed during storage, handling, installation, use, closure, and transport by the user before final disposal. XXI. List the steps for providing on-going care of the patient until an ALS provider arrives 1. Continue to support respirations as necessary which may include positive pressure ventilation via bag-valve mask (BVM) and supplemental oxygen; 2. Monitor for signs and symptoms of opioid withdrawal (agitation, vomiting, tachycardia); 3. Complete BLS Secondary Survey (allergies, medications, past medical history, etc.). 4. Ensure ALS transport is en route.. Prepare to initiate basic life support procedures (CPR, AED) If the patient s condition does not improve within 2-3 minutes after administering the initial dose of naloxone, or if the patient s condition worsens (increasing respiratory depression, decreasing mental status), may repeat a second dose (for adults only). The total maximum dose not to exceed 4mg of naloxone for adults and 2mg of naloxone for pediatrics. Demonstrate the proper way to dispose of a contaminated item/sharp Remind participants that pediatric patients shall be administered only one (1) dose of Naloxone. Review of Minimally Interrupted Cardiac Resuscitation (MICR) and highlight that is contraindicated for respiratory or trauma-induced cardiac arrest. Respiratory-induced cardiac arrests include: Drowning Hanging / asphyxiation Severe asthma Apnea (absent breathing) Page 9 of 10 09/2017
1 For adult patients that suffer from respiratory-induced cardiac arrest, initiate CPR at 30:2. XXII. Transfer of Care Upon arrival of the ALS transport unit, provide the transport paramedic with a complete report and history of care. This report should include: (1) Findings from the initial assessment; (2) History of the treatment provided to the patient by EMS; and, (3) The current status of the patient. XXIII. Clearly document use on patient care report The patient care report (PCR) is a legal document that speaks for the patient when they are unable to do so. The PCR documentation must be clear, concise and accurate to ensure proper continuum of care once the patient arrives at the hospital. XXIV. Written Test secondary to overdose Highlight 1. Found 2. Did 3. Have Documentation review. If it s not documented it didn t happen. Answer any questions and repeat disclaimer. Once an SJCEMSA accredited paramedic arrives on scene, that paramedic will provide all further ALS Patient care. No EMT Optional Skills will be performed or authorized in the presence of an SJCEMSA accredited paramedic. XXV. Skills Lab 30-0 Case Scenarios 1 XXVI. Skill Competency Test and Course Evaluation 200-240 Total Course Time Use 09/18/1 Naloxone Intranasal (IN) Skills Competency Verification Form Page 10 of 10 09/2017