BLS INTRANASAL NALOXONE Vermont Statewide EMS Protocol Education

Objectives • By the end of this course the EMT will be able to: • • Recognize the signs and symptoms of an overdose Identify the indications, contraindications, and possible adverse reactions of Naloxone Prepare and administer intranasal Naloxone Describe how continued support will be provided to the patient Vermont Department of Health - EMS

History In 2007, approximately 27, 000 unintentional drug overdose deaths occurred in the United States, one death every 19 minutes. About half of these deaths involved prescription opioid analgesics. Nearly 257 million prescriptions for prescription opioids were written in 2009 alone Vermont Department of Health - EMS

Vermont Department of Health - EMS

We need to be concerned with more than just heroin! Vermont Department of Health - EMS

Treatment History EMTs have provided respiratory support, but reversal of the cause of hypoventilation is the definitive treatment. Reversal of opiate intoxication reduces or eliminates the duration of hypoventilation/hypoxia. Prolonged hypoventilation complications include hypercarbia, sedation, hypoxia, aspiration, and death. Vermont Department of Health - EMS

Narcan Usage Protocol Vermont Department of Health - EMS

Opioids Synthetic or semi-synthetic alkaloid that acts in the Central Nervous System to: Decrease the perception of pain Decrease the reaction to pain Increase pain tolerance May be prescribed for acute pain, debilitating pain, or chronic pain as part of palliative care (e. g. , cancer). Vermont Department of Health - EMS

Opioids versus Opiates are alkaloid derived from the opium poppy plant and are non-synthetic. Examples are: Morphine Codeine Heroin Vermont Department of Health - EMS

Opioids & Opiates Tolerance and/or addiction may occur, requiring increasing doses for the same effect. Common side effects include: Nausea and vomiting Drowsiness Itching Dry mouth Miosis (constricted pupils) Constipation Vermont Department of Health - EMS

Opioids & Opiates May Include: Buprenorphine Morphine Butorphanol (Stadol) Nalbuphine (Nubain) Codeine Oxycodone (Percocet/Percodan) Fentanyl (duragesic patch) Oxymorphone Hydrocodone Pentazocine (Vicodin) (Talwin) Hydromorphone Paregoric (Dilaudid) Propoxyphene - EMS Meperidine Vermont Department of Health(Darvon)

Heroin is an illegal opiate which may be injected, snorted, or smoked. It has many street names. Vermont Department of Health - EMS

Remember… Remember, these common street drugs are not opioids/opiates and therefore not addressed by this portion of the protocol: cocaine, LSD, ecstasy, sedatives/tranquilizers, and marijuana. Vermont Department of Health - EMS

Opioid & Opiate Addiction and Treatment Drugs Methadone Opioid which may be used as a pain reliever, but commonly prescribed to minimize the effects of opioid withdrawal. Suboxone Opioid (Buprenorphine) and Naloxone combined to both minimize effects of opioid withdrawal while blocking the effects of euphoria (“high”). Vermont Department of Health - EMS

Who’s at High Risk for Overdose? Individuals demonstrating drug-seeking behavior (e. g. , frequent ED visits, or accessing care from multiple doctors) High dose users Prescription pain-killer users (often not their own prescriptions) IV drug users Formers users recently released from incarceration or drug rehabilitation program Vermont Department of Health - EMS

Who Else is at Risk? Over-medicated elderly patients Patients with pain relieving patches Children with access to prescription pain-killers Vermont Department of Health - EMS

Target Population Vermont Department of Health - EMS

Naloxone (Narcan) is an opioid (narcotic) antagonist that can reverse Central Nervous System and respiratory depression secondary to an overdose of opioids/opiates. Naloxone is NOT effective against respiratory depression due to non-opioid drugs. Vermont Department of Health - EMS

Why Intranasal Naloxone? Minimizes risk for blood borne pathogen exposure (no needle) May be administered rapidly and painlessly Onset of action is 35 minutes, peak effect is 12 -20 Vermont Department of Health - EMS minutes

Why Intranasal Naloxone? Works almost as quickly as IV route since nasal mucosa is highly vascularize d and absorbs drugs directly into the blood stream. Vermont Department of Health - EMS

Why an Atomizer? Briskly compressi ng the syringe converts the liquid drug to a fine atomized mist. Vermont Department of Health - EMS

On Scene You may know you are responding to a suspected overdose, or you may be told upon arrival. Scene safety/BSI is a top priority. Do you have police present or responding? Remain non-judgmental and nonconfrontational. Ask bystander(s) what and when the patient injected, ingested, or inhaled (or if a transdermal Vermont patch has been used). Department of Health - EMS

On Scene Drug use clues: Multiple bottles of the same prescription medication that don’t belong to the patient or anyone else at Vermont Department of Health - EMS that residence

On Scene Drug use clues: “Packaged” drugs Drug kits “Track Marks” Vermont Department of Health - EMS

Opioid/Opiate Toxidrome Signs & Symptoms: Unresponsive or minimally responsive with a pulse Respiratory arrest Depressed respiratory rate (< 6 per minute) Agonal respirations Cyanosis Miosis (constricted pupils) Decreased mental status or confusion Slurred speech and/or difficulty ambulating Vermont Department of Health - EMS Nausea/vomiting

Indications for the use of Naloxone Respiratory arrest or hypoventilation with evidence of opioid/opiate use (bystander report, drug paraphernalia, opioid prescription bottles, “track marks”) and/or Recognition of the opiate/opioid toxidrome Vermont Department of Health - EMS

Narcan Usage Protocol Vermont Department of Health - EMS

Contraindications Known hypersensitivity (rare) Abnormal breath sounds on auscultation (wheezing, unequal breath sounds, rales or crackles or rhonchi) Recent seizure (by report or signs) Head/facial trauma Nasal trauma (obstruction and/or epistaxis) Cardiopulmonary arrest Vermont Department of Health - EMS

Nasal Atomizer Use Ensure scene safety! Maintain appropriate Body Substance Isolation (BSI) Maintain open airway and assist ventilations (use BMV and nasal airway if unresponsive with a pulse) Suction as needed Vermont Department of Health - EMS

Nasal Atomizer Use Assess level of consciousness and vital signs Activate ALS if not already responding Initiate transport as soon as possible (do not wait on scene for ALS) Vermont Department of Health - EMS

Nasal Atomizer Use The “Six Rights” for Medication Administration: Right Patient Right Time Right Dose Right Route Right Drug Right Documentation Vermont Department of Health - EMS

Adult Nasal Atomizer Use Administer Naloxone 2. 0 mg Nasal via atomizer (1. 0 mg per nostril) Continue ventilating the patient as needed Consider contacting poison control if polysubstance use is suspected : (800) 222 -1222 Vermont Department of Health - EMS

Nasal Atomizer Use Vermont Department of Health - EMS

Preparation: Step 1 Vermont Department of Health - EMS

Preparation: Step 2 Vermont Department of Health - EMS

Preparation: Step 3 Vermont Department of Health - EMS

Preparation: Step 4 Vermont Department of Health - EMS

One Luer Attached Atomizer Vermont Department of Health - EMS

Administration Ventilate the patient with a BVM Assess the patient to ensure their nasal cavity is free of blood or mucous (suction if needed) Control the patient’s head with one hand Gently, but firmly, place the atomizer within one nostril, carefully occluding the opposite nostril Vermont Department of Health - EMS

Administration Vermont Department of Health - EMS

Documentation As always, carefully document, including: Patient presentation (neuro, respiratory, cardiac) Signs and symptoms (before and after treatment) Vital signs (before and after treatment) Naloxone administration prior to EMS arrival Clinical response Any use of physical restraint Record time drug was administered, amount, and route, for example: “ 19: 21, Naloxone 2. 0 mg nasal via atomizer” Vermont Department of Health - EMS

Avoid “Tunnel Vision” Vermont Department of Health - EMS

Other Possibilities The patient has taken an amount of opioids that is more than the Naloxone is able to counter. Maybe it is not an overdose or other substances are involved! What other conditions may have similar signs and symptoms? Consider medical or traumatic causes. How would this change your treatment plan? Vermont Department of Health - EMS

Adverse Reactions Use CAUTION when administering Naloxone to narcotic dependent patients! Rapid opiate withdrawal may cause nausea and vomiting and extreme combativeness. Keep the airway clear and be prepared to suction! Vermont Department of Health - EMS

Adverse Reactions Rapid opiate withdrawal may also cause: Runny nose Diaphoresis (excessive sweating) Tachycardia Tremulousness Hypertension (high blood pressure) Hypotension Cardiac disturbances, including cardiac arrest Vermont Department of Health - EMS

Critical Reminder DO NOT get distracted by drug administratio n! Be sure to ventilate properly as needed! Vermont Department of Health - EMS

Pediatrics When an opioid overdose is suspected in a pediatric patient (<15): Infant: 0. 5 mg per nostril (total 1 mg) Child: 1 mg per nostril (total 2 mg) Vermont Department of Health - EMS

Pediatrics Remember, pediatrics have smaller nares and some of the drug will run out of the nose and down the back of the throat! Vermont Department of Health - EMS

Patient Refusals Do not “treat and release” A refusal must be signed by a patient who can reasonably be determined to have the capacity to make an informed decision to refuse further care An overdose patient is unlikely to fall into this category Request police assistance if needed Vermont Department of Health - EMS

The Vermont Opiate Overdose Prevention Program Be aware: the general public can access and use Naloxone through community overdose prevention pilot programs and/or direct prescriptions from healthcare providers. Vermont Department of Health - EMS

Skills Practice Given a scenario: Prepare a Naloxone atomizer using the required equipment Demonstrate administration of intranasal Naloxone on an adult intubation head Demonstrate as well as explain how you will provide continued patient support Vermont Department of Health - EMS

Course Summary What we learned: Why Naloxone was added as an option for BLS What an opioid overdose looks like The indications and contraindications Possible adverse reactions and management How to prepare a Naloxone Atomizer Vermont Department of Health - EMS

Credit and Acknowledgements Central MA EMS Corporation EMS Region II www. cmemsc. org Vermont Department of Health - EMS

References Centers for Disease Control Drugs. com Federal Drug Administration MDPH Bureau of Substance Abuse Services N. O. M. A. D. (Not One More Anonymous Death Overdose Prevention Project) VTEMS Statewide Protocols Vermont Department of Health - EMS