Overdoses

[HeatherISU]

I have a situation that occurred and I was wondering about alternatives that could have been explored.

Late night admit 20yo F with polydrug intentional overdose on an Emergency Detention. Up from ER coming in and out of extreme agitation then lethargy. The pt would really fall asleep while talking. Apneic episodes 10-15 seconds with desats into 75%, pt remains pink. One nurse had to sternal rub her awake, and she would become agitated again.

Pt received no medications other than NS in ER. No charcoal r/t pt stating took meds IV. No narcan given. (pt positive for benzos and opiates)

Telephone call made to admitting doctor. I told him exactly as I have listed above. I'm still new, and I mentioned our detox policies (which are evidently for alcoholics, not ODs...which he made clear in a very annoyed manor. Oops!) He says to me... "I can't give her ativan because of her apnea. Narcan will just make her crazier. Go for a rapid sequence intubation"

I wasn't expecting him to say intubation, but I wrote down the order and informed the other nurses assisting with her admission. I got some "Are you serious?!" reactions, and one nurse in particular seemed annoyed by this, as if we were intubating her instead of actually caring for her... or taking the easy way out. I asked a senior nurse who opinion I absolutely trust, and she said that intubation made sense since she was at risk for anpea/seizures with an unprotected airway.

What have you seen done in these situations? Were there alternatives? Was intubation too extreme or justified? Thanks for any input. I know doctors rely heavily on our assessments given over a telephone report, so knowing a future "recommendation" for the SBAR report would be lovely.

[bpf1987]

I personally love ODs in the ER. So complicated. Psych, physio, pure nursing creativiy. I've seen RSI for that but depending on what type of information we had on what she took and how long ago I think we would have charcoaled her, ngt maybe, she sounds like she needed more than saline. She must not have been too legthargic in the ER bc I think they would have narcaned her.

[bpf1987]

Ahhh I missed the ivda part. I shouldn't post after a night shift. Boo

[morte, LPN, LVN]

i dont think that charcoal would have been a bad idea r/t i wouldnt trust an addict to tell me the truth....especially a suicidal one

[meandragonbrett]

I see no problem with RSI. The reason being is that she's having periods of apnea...she is obviously unable to protect her airway.

[PAERRN20]

ER nurse here.

I think charcoal would have been appropriate even though the patient said the drugs were IV. How do you know she didn't swallow a few pills and intentionally throw the physician for a loop. I also agree with the RSI. We RSI many, many overdoses. Usually it is for airway protection but it can occasionally be for

the staff's safety. In an agitated patient you can't give them Ativan (or really any other depressant) because that will aggravate their respiratory status. You can't Narcan them because that will agitate them even further. What's the other option? RSI. I know this isn't the right answer for all situations but sometimes tubing them works out best for all parties involved.

[WindwardOahuRN, RN]

We would go for the RSI, absolutely. Apnea, the patient's inability to protect her airway, the possibility of aspiration, the need to safely control her agitation---all good rationales for intubation. Drop an OGT at the same time, of course, to suction out gastric contents to help prevent vomiting and aspiration and then instill charcoal.

I've seen this scenario many times in drug overdoses and alcohol intoxication. In the great majority of cases the patient is extubated the next day or even within hours.

It's the safest choice considering the many things that could go wrong here. Her sats went down to 75%? What if they had continued to drop? I see hypoxia, bradycardia, and a code.

Better safe than sorry!

[hypocaffeinemia, BSN, RN]

RSI makes sense to me if she's having apnea that long. If it was just opiates you could do a narcan drip and cover her with benzos for agitation, but the double whammy means that if you were to actively reverse both you'd have one hell of a wild and withdrawlin' crazy on your hand. Intubate to maintain airway and use propofol for sedation, letting everything she took wear off before weaning.

[PICNICRN, BSN, RN]

From my experience with these pts(whom are mostly teens with me) RSI would absolutely be what we would do. Can't keep um calm without becoming totally obtunded. If she is a chronic opiod user like suspected, Narcan could make her seize, not to mention she would then become a MANIAC you could not sedate. Bottom line is she can't protect her airway- apnea/lethergy/desats.

Intubation with propofol and extubate in the morning- thats the plan I'd be happy with.

Plus...... an intubated overdose is much better than a Maniac any day:up:

[matt2401, MSN, RN]

RSI is the best and safest way to go. I bring this expierence from my paramedic years of dealing with many, many ODs. Most are polysubstance and difficult to treat. If you give narcan you run the risk of reversing the narcotic component and causing vomiting, but still too lethargic from other meds (benzos and soma go hand in hand with narcs) to protect the airway. Now you have aspiration pneumonia, oops. Ah, but there is Romazicon one might say; well only if you want to start seizures from acute benzo reversal (and no way to treat them because all the benzo receptor sites are bound). Activated charcoal has never been shown to produce any better outcomes. Plus, dumping fluids in the stomach of a sedated and lethargic patient would make me nervous for aspiration. The best and safest approach is to RSI and let the meds wear off. If the patient goes into DTs, all the better to manage on an Ativan or propofol gtt while vented. I would completely agree with the order to intubate, it is safest for the patient and the staff. I try and limit Narcan use to when it is known to only be narcotic (i.e. patient got 2 mg Dilaudid and now is over sedated).

On the flip side, if the intubation was over aggresive then the gases will be great the patient will wake up and they will get extubated. People get intubated every day in the OR for elective procedures so its not like its a "punishment" or non-treatment.

Here is an SBAR suggestion that you asked for:

S: Patient was admitted to the unit from the ER with extreme lethargy, poor ventilations and periods of apnea. VS are....blah blah blah, latest ABG is: blah blah blah

B: Patient presented with intentional OD of known/unknown subtances, reportedly taken by IV route. Treatment prior to the unit was....

A: I am calling because I am concerned about her airway protection and ventilation status

R: Defer this one and let the Doc make the first "recommendation". Some Docs LOATHE being told what to do, even though you are coming from the patient advocate role. If you agree with it, fantastic. Doc gets to be 'Doc' and save you having to defend yourself. If you dont agree, then make your recommendation. Getting the orders you want can be a silly little game sometimes, esp when you are still new. Plus, the doc just might know something we dont (happens occasionally, )

Keep it short, sweet and to the point. Have all your labs ready to respond with (but not necessarily offer).

Hope it helps!

Matt

[HeatherISU]

You guys hit it right on the head. She was intubated/sedated with propofol. (She barely responded to the versed.) Extubated in the AM. I just had one nurse that thought I was crazy and actually said that she would have drug her med cart in there to sit with her and manually wake her up from each apneic spell to avoid intubation.

I didn't know Narcan ran the risk of putting the pt into seizures. Interesting.

[meandragonbrett]

I just had one nurse that thought I was crazy and actually said that she would have drug her med cart in there to sit with her and manually wake her up from each apneic spell to avoid intubation.

SHE is the crazy one. Not you!