Sierra Sacramento Valley EMS Agency BLS IN NALOXONE ADMINISTRATION OPTIONAL SKILL (UPDATED 06/2017) Acknowledgement: Siskiyou County SO - source of some slide content
In order for PSFA, EMR or EMT personnel to administer IN naloxone, they must: Be part of the organized EMS system, functioning under the oversight of an S-SV EMS approved BLS optional skills provider Be authorized by the approved BLS optional skills provider to administer IN naloxone Have received adequate training on IN naloxone administration
Education/Training Purpose and Objectives Purpose o To enable authorized PSFA, EMR and EMT personnel to administer IN naloxone to patients in the prehospital setting Objectives o Review background and causes of opioid overdoses o Identify signs and symptoms of an opioid overdose o Understand naloxone actions, indications, contraindications, dose, route, warnings and potential adverse reactions o Understand intranasal medication delivery o Describe/demonstrate treatment for suspected opioid overdose
Opioid Overdose Background & Causes Identification of an Opioid Overdose Naloxone Information Intranasal (IN) Medication Administration
Opioid Overdose Background & Causes About opioids o Sedative narcotics Used primarily in medicine for pain relief Induce euphoria users feel warm, drowsy and content Depressants high levels can suppress the urge to breathe Street opioids include heroin, street fentanyl, M-18, etc. Prescription opioids included Hydrocodone/Norco, Oxycodone, morphine, fentanyl, etc. Type, strength and consumption method influences to what degree and how long their effects last
Opioid Overdose Background & Causes About opioids (cont.) o Other opioids of concern Street fentanyl ( disguised as Norco) M-18 Synthetic opioid 100 times more potent than fentanyl 10,000 times more potent than morphine Street fentanyl M-18
Opioid Overdose Background & Causes About opioids (cont.) o Other opioids of concern Carfentanil (elephant tranquilizer) Analogue of fentanyl 100 times more potent than fentanyl 10,000 times more potent than morphine
Opioid Overdose Background & Causes Opioid abuse is a major public health epidemic o 16,325 prescription opioid-related deaths in the US in 2013 (4x the number of deaths that occurred in 1999) o 8,257 deaths in the US from heroin in 2013 o 7,428 prescription opioid-related deaths in California from 2008 to 2012 (16.5% increase from 2006) o 1,800 opioid-related deaths in California in 2012 alone (72% involved prescription pain medications)
Opioid Overdose Background & Causes Efforts undertaken to combat the crisis o Calls to improve opioid prescription practices o Greater access to addiction treatment o Public naloxone distribution programs 2015 California State Board of Pharmacy emergency regulations allow pharmacists to dispense naloxone without a prescription o Increased utilization of naloxone by BLS first responders
Opioid Overdose Background & Causes About the solution o Abstinence from illegal drug use is the most effective overdose prevention tool Most users attempt to achieve abstinence - on average this process takes 9 years/4 episodes of care to achieve success o Naloxone administration: Temporarily reverses the effects of opioids Only given when the patient is unresponsive and breathing ineffectively or not at all Safe and effective has no effect on non-opioid overdoses
Opioid Overdose Identification Recognize overdose symptoms Recognize the drug Recognize drug paraphernalia Recognition of need for naloxone administration Look for physical signs and symptoms of overdose as well as drug paraphernalia and/or pill bottles If in doubt or uncertain and patient is unresponsive with respiratory depression consider naloxone administration
Opioid Overdose Identification REALLY HIGH (NALOXONE NOT INDICATED) OVERDOSE (ADMINISTER NALOXONE) Muscles become relaxed Deep snoring or gurgling (death rattle) Speech is slowed/slurred Infrequent (less than 12 breaths per minute) or not breathing Sleepy looking Pale, clammy skin Nodding Heavy nod Will respond to stimulation like yelling, sternal rub, pinching, etc. No response to stimulation
Naloxone Information Naloxone actions o Temporarily blocks the effects of opioids resulting in improved respiratory and neurological status Naloxone onset and duration o Works in 1 3 minutes o Lasts up to 30 60 minutes Naloxone contraindications o Known hypersensitivity (rare)
Naloxone Information Naloxone warnings o May induce opioid withdrawal in patients who are physically dependent o Certain drugs may require much higher naloxone doses Naloxone potential adverse reactions o Rapid or irregular heart rate o High blood pressure o Nausea/vomiting o Diaphoresis (sweating)
Intranasal (IN) Medication Administration IN administration o Uncomplicated and convenient o The nose is an easy access point for medication delivery o Painless, no shots required o Eliminates any risk of needle stick
Intranasal (IN) Medication Administration IN administration (cont.) o The smelling area in the nose (olfactory mucosa) is in direct contact with the brain and CSF o Medications absorbed across the olfactory mucosa directly enter the CSF and provide a rapid/direct route for drug delivery to the brain Olfactory mucosa Nerve CSF Brain Highly Vascular Nasal Mucosa
Intranasal (IN) Medication Administration IN administration (cont.) o Bioavailability = how much medication ends up in the blood stream Intravenous (IV) medications have 100% bioavailability Oral medications are have 5% - 10% bioavailability due to destruction in the gut and liver Intranasal (IN) medications vary, but IN naloxone approaches 100% bioavailability (same as when given IV) Naloxone IV and IN administration serum levels are identical after about 2 3 minutes
Intranasal (IN) Medication Administration IN administration (cont.) o If there is something wrong with the nasal mucosa, it may not absorb IN administered medications effectively examples: Vasoconstrictors, such as cocaine, prevent medication absorption Bloody nose, nasal congestion and/or mucous discharge may prevent medication absorption Destruction of nasal mucosa (surgery, past cocaine abuse, etc.) results in no mucosa to absorb the medication
Treatment Of Suspected Opioid Overdose
Treatment Of Suspected Opioid Overdose Ensure appropriate EMS units have been requested Ensure scene safety o Utilize appropriate personal protective equipment (PPE) o Be aware of potential hazards Needles Hazardous materials Bystanders, nearby traffic, etc.
Treatment Of Suspected Opioid Overdose Assess patient o Stimulate shake and shout o If pulseless, begin chest compressions o Assess/support respiratory status o Administer high flow O 2 (if available) o If no response to stimulation and continued poor/absent breathing, administer intranasal (IN) naloxone
Treatment Of Suspected Opioid Overdose Naloxone 2 mg preloaded syringe with mucosal atomizer device (MAD) o Administer ½ dose in each nostril when patient exhales and before inhalation
Treatment Of Suspected Opioid Overdose NARCAN Nasal Spray 4 mg o If using this type, all medication can be administered in one nostril o Administer when patient exhales and before inhalation
Treatment Of Suspected Opioid Overdose Additional treatment notes: o Observe for improved breathing/consciousness, if no improvement assist breathing with BVM (if available) or begin CPR if appropriate o If CPR is not necessary and it is possible, place patient in recovery position to avoid potential for inhaling any vomit o Consider additional doses of naloxone if necessary and available
Treatment Of Suspected Opioid Overdose Additional treatment notes (cont.) o Use naloxone with caution in patients with significant trauma who have not been adequately immobilized Consider the concurrent need for appropriate immobilization/spinal motion restriction o Although rare, be alert for sudden agitated/violent behavior o Because naloxone stops the effects of opioids, an opioid dependent person may experience acute withdrawal symptoms
Treatment Of Suspected Opioid Overdose Other responsibilities o Inform other appropriate EMS providers and/or the receiving hospital of any pertinent details related to the naloxone administration o Adequately document the naloxone administration for reporting and QI review requirements
Treatment Of Suspected Opioid Overdose Keep in mind o Naloxone is only for unconscious patients breathing ineffectively or not at all Do not use prophylactically or for individuals who are simply under the influence without respiratory depression o Naloxone only treats the effects of opioids If no opioids are present, there is no effect from administering naloxone Naloxone will not treat the effects of alcohol, cocaine, or other substances