Trouble with Narcan

mamamo · Jun 23, 2006

I'd be more worried about an 84 year old taking approximately 12 mg of dilaudid per day than anything else, imho. Of course, she's developed tolerance to it but that's a lot of meds; elderly people in general have a harder time excreting and breaking down drugs so along with tolerance and a high intake of the drug, she may have been predisposed to its toxicity.
And if you were not in the ambulance, it'd be hard to say that she didn't have a turn for the worse while there and be more unresponsive, etc. Sounds to me like narcan wasn't her only problem. Sorry to sound so blunt, but I have a hard time with the tone of the post as it seems like you want to put all the "blame" in one place. That doesn't fly with me as it could very easily be any healthcare professional, nurse, doctor, etc. besides a paramedic that might assess the patient's level of consciousness, given a history that looks like dilaudid overdose, and administer narcan.

what history of overdose? 4mg at 4am and 4 mg at 1 am? 9 hours apart? hardly an overdose. I would like to know what she could take for pain when dilaudid did is the only one she can tolerate. any ideas?

Altra, BSN, RN · Jun 23, 2006

[/b]what history of overdose? 4mg at 4am and 4 mg at 1 am? 9 hours apart? hardly an overdose. I would like to know what she could take for pain when dilaudid did is the only one she can tolerate. any ideas?

Indy was referring to a "history" meaning a "history" of the events leading to the need for medical treatment now. It's a triage term - when I triage someone in the ER, I get a "history" of what led them to present to the ER today.

Just for clarification, your earlier post said she was prescribed 4mg Dilaudid q 6 hours, but a later post says twice per day. Just curious which it is ...

8mg of Dilaudid, every day, is a hell of a lot of Dilaudid.

If her respiratory function was compromised or on the way to being compromised, I absolutely agree with the medics' decision to administer Narcan.

Eric01 · Jun 23, 2006

Here is a Narcan tip that I have found helpful in the past...dilute the .4 mg in 9 mL of NaCl so it is .04 mg/mL and then give it very slowly 1-2 mLs at a time. Most patients do not need the entire dose of narcan to reverse respiratory depression caused by opioids. If you give small doses, you can reveres resp. depression without reversing all your analgesia and the patient is usually not as uncomfortable/agitated. By the way, Narcan can also cause HTN, severe tachycardia, and pulmonary edema. Note: This is only for resp. depression...not heroine OD (never tried it b/c I've never worked in the ER).

I currently work on a surgery floor where we occasionally get APS orders for PCA's. Our pre-printed orders from APS include a narcan protocol. They just revised it recently. Now for RR about 8 and rouses briefly with difficulty, we give one amp narcan straight IVP; for RR

SilentfadesRPA · Jun 23, 2006

I am sure that EMS did not take it upon themselves and give Narcan but had standing orders. These are alwasys preapproved by the EMS physician

and standards of care as well as the EMS review board in all cases.

Cardiac arrythmia in an 84yr old woman with pneumonia,eitiology unknown respitory depression with history of opiod drug use (yes I realize prescribed) , renal impairment, and who is unresponsive (whatever the cause) is to be looked out for.

I also doubt that the renal impairment occured in the ambulance but was already an pre EMS ongoing factor perhaps due to dehydration alone.

Should you feel that strong about no narcan I would not call EMS again unless you have a written MD order not to administer what he/she feels.

And then it would still be questionable if they have to comply with an outside MD verses thier EMS protocol.

Having a patient in an unresponsive state is NOT good pain management seems to be the bottom line here.

I do empathize withy you that your mother is so very ill.

I also think however that the pre hospital treatment was not inappropriate.

What would your feelings be if your mom died and they found out that she had not exreted the opioids due to renal failure or drug induced resp failure?

It must have been very overwhelming for you to see and have expirienced all of this and know that your mom pain has not been correctly addressed or properly treated.

You and your mom are in my thoughts.

Sincerely,

Marc

" I look until the hills whence cometh my help ... " Psalms

NYNewGrad · Jun 23, 2006

Yup, I agree that Narcan *was* the right choice to give an older lady with recent narcotic use. Depending on tolerance, body wt., etc. I think the dose you quoted here may be to the high side.

On another note, I gave Narcan once, as a brand new grad still on orientation. Pt was a LOL who got morphine 5mg IVP 3 hours earlier, and now had RR of 4. New interns on the floor were mostly clueless (and so was I) and said push the full dose of Narcan = 2 mg. OUCH! I hadnt even finished pushing the dose when the pt woke up SCREAMING! Let's just say it worked, probably too well. I was too new and inexperienced to know to dilute the drug and push it very, very, slowly and only give as much as needed to wake her.

About calling a code, my hosp would be entirely annoyed if you called a code on a/o with a pulse! ;-)

mced · Jun 23, 2006

Narcan is a great drug. Just make sure that you or EMS has restrained the patient prior to administration. Same goes for Romazicon.

allnurses Guide · Jun 23, 2006

I've seen "non-user" patients go ballistic after Narcan, I think it is just an infrequent side effect. We are always ready for it to happen, but it is rare.

Mamamo, I hear your pain coming through. When my DH was rapidly going downhill, I though I had given too much Morphine, and begged them for Narcan. That wasn't the problem though, he was unresponsive from other complications, and died that night from them. Trying to back track and pinpoint one event that caused the problems rarely works.

EMS gives Narcan, and they are very familiar with it, and know what to do. If your Mom had the arrhythmias from that, its better than no rhythm at all from the other stuff that could be going wrong. I'm glad she survived.

jannrn · Jun 23, 2006

Has anyone had similar reactions from Nubain? the drug can act similarly.... had that happen to a pt once, happened to be the nurse manager for OR!!! who had a hyst.... wiped her pain control right away, incision burning.... it was given for itching by the way....

mamamo · Jun 23, 2006

Just for clarification, your earlier post said she was prescribed 4mg Dilaudid q 6 hours, but a later post says twice per day. Just curious which it is ...

MLOS

She was allowed 4 mg of dilaudid every 4 to 6 hours. We only allow her 4 mg twice a day as she in lala land with any more. She seems to be able to cope with that. This has been prescribed and discussed with her primary, pain, lung and heart docs. As her primary care taker I have requested they never give it to her again. Her renal failure happened once in ER not in the ambulance. If they had done that to my husband who is on 149 mg of dilaudid twice a day for metastasized prostate cancer it would have killed him

I do not believe everyone is candidate for Narcan I have heard nothing but horror stories from the people who have had it including other nurses who had at one time or another been transfered by ambulance.

Ortho_RN · Jun 23, 2006

We had a patient who was Total Shoulder Sx and she stayed zonked for 2 days, and finally the doctor had enough and told us to give her Narcan... Keep in my family is all freaking out because momma won't stay awake long enough to chew her food.... We go in give the narcan and as always patient wakes up automatically, swinging her arms around, yelling.. and then proceed to projectile vomit everywhere... But not 10mins after we do this and get her calmed back down the family asks.. "When can she have something for the pain???" !!!!!!

rn29306 · Jun 23, 2006

Now for RR about 8 and rouses briefly with difficulty, we give one amp narcan straight IVP; for RR
That is a terrible protocol, no offense to your institution or the RNs that work there. Have you seen this followed lately? I can only imagine the results.

SophiaRN · Jun 23, 2006

Am I the only one bothered by the comment, "I didn't want that stupid junkie SOB enjoying it?" When will we begin to realize that addiction is a disease?? I am bothered by this attitude in our profession. I know how difficult and manipulative these patients can be, but believe we should be looking at them as people who are suffering not, as I've heard reference to them on the floor as, "the junkie in room 12", or "the professional drinker in room 11". Let's try to remember they are someone's Mother, Father, Brother, Sister, etc. Just my own 2 cents worth...