Transcript Slides

Central MA EMS Corporation
EMS Region II
www.cmemsc.org
Naloxone
Version 2a
(2014)
Location Logistics
Emergency Exits
 Restrooms
 Breaks
 Cell phones
 Interruptions (You must be present for
the entire course to earn OEMS credit.)

This Course…
Includes the training required for First
Responder (police/fire) agencies electing
the optional skill of naloxone
 Meets the required training for EMTs
 Does not result in certification

OEMS CE Credits

This course is eligible for 1.5 hours
OEMS credit for all EMT levels (use for
Local or Individual Category).

The OEMS Approval Number is listed on
the course completion document you’ll
receive at the end of this program.
Course Overview
Introductions
 Goal, Purpose, Objectives and History
 The “Why, What, and How” of Naloxone
 Course Summary & Questions
 Written Quiz
 Skills Practical Assessment (Required)
 Course Evaluation
 Roster & Course Completion Document

Goal (What are we trying to accomplish?)
Reduce death from opioid overdose
Purpose (Why are we here today?)
To teach police & fire department First
Responders and MA certified EMTs how to
administer Naloxone in accordance with
MDPH/OEMS AR 2-100 and EMS
Prehospital Treatment Protocols
Objectives
By the end of this course the student will:
 Recognize the signs and symptoms of an
overdose
 Identify the indications, contraindications
and possible adverse reactions of Naloxone
 Prepare and administer Naloxone (intranasal
& auto-injector)
 Describe how continued support will be
provided to the patient
History (state data 2000-2009)
Poisonings, most of which are ODs, continued to be
the leading cause of injury deaths in MA and have
increased at 4.9% per year since 2000.
History
Opioids, including but
not limited to:
 Heroin
 Oxycodone
 Morphine
 Codeine, and
 Methadone
continued to be the class
of drugs most associated
with poisoning deaths
(67%)
History (Legislation)
On March 27, 2014,
Governor Deval
Patrick declared the
state’s opioid addiction
epidemic a public
health emergency,
directing MDPH to
allow First Responders
the option to carry
and administer
naloxone.
And later that same day…
History (Protocols)
OEMS changes
naloxone
administration from
an option to a
required skill for all
EMTs.
History (Protocols)
Demand for
intranasal naloxone
causes shortages,
leading OEMS to
release an emergency
protocol change on
10/21/14 allowing
naloxone
administration by
auto-injector as well.
Naloxone

Naloxone (Narcan) is an opioid (narcotic) antagonist that
can reverse Central Nervous System and respiratory
depression secondary to an overdose of opioids.

Naloxone is not effective against respiratory
depression due to non-opioid drugs.
Opioids
Synthetic or semi-synthetic alkaloid that acts
on 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).
Opioid vs. Opiates
Opiates are an
alkaloid derived
from the opium
poppy plant.
(non-synthetic)
Opioids
may include:
Buprenorphine
Butorphanol (Stadol)
Codeine
Fentanyl (Duragesic patch)
Hydrocodone (Vicodin)
Hydromorphone (Dilaudid)
Meperidine (Demerol)
Morphine
Nalbuphine (Nubain)
Oxycodone (Percocet/Percodan)
Oxymorphone
Pentazocine (Talwin)
Paregoric
Propoxyphene (Darvon)
Opioids
Heroin is an illegal Opioid which may be injected, snorted,
or smoked. Street names include:
Big H
Boy
Capital H
China white
Chiva
Dead on arrival
Diesel
Dope
Eighth
Good HH
Hell dust
Horse
Junk
Mexican horse
Mud
Poppy
Smack
Thunder
Train
White junk
Opioids


Tolerance and/or addiction may occur,
requiring increasing doses for the same
effect
Common side effects include:
-Nausea and vomiting
-Drowsiness
-Constricted or “pin-point” pupils
-Itching
-Dry mouth
-Constipation
Treatment Drugs
Methadone
Opioid which may be used as a pain reliever,
but commonly prescribed to minimize the
effects of opioid withdrawal

Suboxone (tablets & film strips)
Opioid (Buprenorhpine) and Naloxone
combined to both minimize effects of opioid
withdrawal while blocking the effects of
euphoria (“high”)

Who’s At High Risk?
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
own prescription)
 IV drug users

Others At Risk
Over-medicated elderly patients
 Patients with pain relieving patches
 Children with access to prescription painkillers

Target Population
The target population for intranasal Naloxone:
 those who use opioids as substances of abuse
 those whose respiratory drive is at a lifethreatening level
Why Intranasal?
Minimizes risk for
blood borne pathogen
exposure (no needle)
 May be administered
rapidly and painlessly
 Onset of action is 3-5
minutes, peak effect is
12-20 minutes

Protect Naloxone from light
Why Intranasal?
Nasal mucosa is highly vascularized and
absorbs drugs directly into the blood
stream.
Why an Atomizer?
Briskly compressing the
syringe converts the liquid
drug to a fine atomized
mist.
This results in broader
mucosal coverage and
better chance of absorption
into the blood stream than
drops that can run straight
back into the throat.
Indications
Respiratory arrest or hypoventilation
 Unresponsive or depressed mental status
 Constricted or “pinpoint” pupils
 Evidence of opiate use (opioid Rx bottles,
drug paraphernalia, “track marks”)

Yarmouth police officers work
to save the life of a 25-year-old
man following an apparent
heroin overdose.
(Yarmouth Police Dept. photo)
Contraindications


Recent seizure (by report or signs)
Head/facial trauma

Nasal trauma (obstruction and/or bloody
nose)
Cardiopulmonary arrest

On Scene
Scene Safety/BSI is a top priority
 EMTs: Are police responding?
 Be non-judgmental and nonconfrontational
 Ask bystanders what and when the
patient injected, ingested, or inhaled (or if
a transdermal patch has been used)
 Was more than one substance used?

On Scene
Drug use clues
Multiple bottles of the same
prescription medication
 Multiple bottles of the same
prescription medication that
don’t belong to the patient or
anyone else at that residence
 Some prescription bottles may
be used to “hide” narcotics
(i.e., pills inside don’t match
what’s on the label)

On Scene
Drug use clues
“Packaged” Drugs
(An “8-ball” of heroin)
Drug Kit
On Scene
Drug use clues
“Track Marks”
Signs & Symptoms
Unresponsive/minimally responsive with
pulse
 Respiratory arrest (not breathing)
 Depressed respiratory rate (<12 per min)

Paramedics work on a
20-year-old man who
collapsed from a drug
overdose after coming
out of a bar.
Source: Herald Sun
Signs & Symptoms
Signs & Symptoms
Decreased mental status or confusion
 Slurred speech and/or difficulty walking
 Bluish skin/mucous membranes
 Nausea/vomiting
 Constricted pupils

Intranasal
Preparation Steps


The following slides are intended only as a
visual preparation for hands-on practice.
Each student must satisfactorily
demonstrate atomizer assembly and
administration on a manikin before being
released into the field to perform this skill
on an actual patient.
Preparation Step 1
You will need:
 One Luer-Jet needle-free
syringe
 One ampule of Naloxone 2.0
mg
 One atomizer
Do not assemble medication on
atomizer until ready to use.
Dosage indicator
Preparation Step 2
Remove the caps from each end of the
Luer-Jet needle-free syringe.
Preparation Step 3
Remove the red cap from the
Naloxone glass vial.
Insert and gently twist the
Naloxone glass vial into the
syringe/adapter.
Preparation Step 4
Attach the nasal atomizer to the opposite end.
Dispose in sharps container as soon as
possible after administration.
Protocol 2.14
Routine Care
Scene safety/Body Substance Isolation
 FRs: ensure ambulance response
 EMTs: activate ALS
 Determine unresponsiveness (call out to
victim/noxious stimulus)
 Check for reduced respirations
 Start rescue breathing (use BVM and nasal
airway /oxygen)

PMDD
…Or the “Four Rights” for Medication
Administration:
 Right Patient (drug overdose)
 Right Medication (Naloxone/check for
clarity)
 Right Date (check expiration)
 Right Dose (refer to protocol)
Administration: Intranasal
Ensure nasal cavity is free of blood or
mucous (EMTs: suction if needed)
 Control patient’s head with one hand
 Place atomizer within one nostril, occlude
opposite nostril

Administration: Intranasal
Aim slightly upwards and toward ear on
same side as nostril
 Briskly compress syringe to administer up
to 1.0 mg of atomized naloxone
 Repeat in other nostril (using both
nostrils doubles the surface area available
for absorption)
 Give second dose if no response after 3-5
minutes

Administration: Auto-Injector
Pull auto-injector from outer case
 Pull off safety guard:


Don’t touch the black base where the
needle comes out!
Administration: Auto-Injector

Place end of auto-injector firmly into the
outer thigh (through clothing if needed)

Press firmly (listen for click & hiss) and
hold in place for 5 seconds
Administration: Auto-Injector
Needle should retract fully into its
housing after administration
 Do not replace safety guard; put autoinjector back into outer case and place in
sharps container

Continued Patient Care
Return to rescue breathing until
spontaneous respirations are restored
 If respirations return to normal, roll
victim on their side to prevent patient
from choking on own vomit

The effects of Naloxone may not last as
long as the effects of the opioid; be
prepared for a return of overdose signs &
symptoms!
 First Responders: Note time of
administration to report to EMTs and
monitor patient until ambulance arrives,
ensuring transfer of care (provide
detailed verbal report)

EMTs: Initiate transport as soon as
possible (don’t wait on scene for ALS)
 Consider contacting poison control if
poly-substance use is suspected: (800)
222-1222
 Confirmed or suspected hypoglycemia: do
not administer oral glucose if patient is
not sufficiently conscious with a normal
gag reflex

Key Points
EMTs: Contact CMED for early entry
notification to the nearest emergency
department
Critical Reminder
Do NOT get distracted by drug
administration
 Be sure to ventilate properly as needed

Avoid “Tunnel Vision”
If level of consciousness does not improve
after five minutes, what could be going on?
Other Possibilities
The patient has taken an amount of
opioids that is more than the Naloxone is
able to counter.
 Maybe it’s not an overdose!
 What other conditions may have similar
signs & symptoms?
 Discuss how each changes the treatment
plan.

Adverse Reactions
Use caution when administering
Naloxone to narcotic dependent patients!
 Rapid opiate withdrawal may cause
nausea & vomiting.
 EMTs: Keep airway clear and be prepared
to suction!

Adverse Reactions
Rapid opiate withdrawal may also cause:
 Agitation, irritability, and violent behavior
 Restlessness and nervousness
 Be prepared to deal with agitated patient
 Maintain the safety of yourself, your
partner and patient when using physical
restraint
Adverse Reactions
Rapid opiate withdrawal may also cause:
 Runny nose, watery eyes
 Excessive sweating
 Shaking, trembling, quivering
 Sneezing, yawning, muscle aches
 Rapid heart rate
 High or low blood pressure
Pediatrics
When opioid overdose is suspected in a
pediatric patient (<15):
 Administer naloxone if needed
 Activate ALS EMS response
 Maintain open airway and assist
ventilations
 Initiate transport as soon as possible
Pediatrics, continued

For infants less than 1 year old, pinch the
middle of the outer thigh before and
during auto-injector administration
Documentation
Carefully document as required by
agency/service & medical director:
 Patient presentation (neurological,
respiratory, cardiac)
 Signs and symptoms (before & after
treatment)
 Vital signs (before & after treatment)
 Naloxone administration by bystanders,
First Responders, EMS
Documentation
Clinical response
 Any use of physical restraint
 Record time drug was administrated,
amount, and route, for example:
 “19:20, Naloxone 2.0 mg nasal via
atomizer” or;
 “19:20, Naloxone 0.4 mg auto-injector”

Patient Refusals
Do not “treat & release”
 A refusal must be signed by a patient who
can reasonably be determined to be
competent to make an informed decision
to refuse care
 An overdose patient is unlikely to fall into
this category
 EMTs should request police assistance if
needed

MDPH Lay Rescuer Program
As part of a MA Department of Public Health
initiative, lay rescuers are administering
intranasal naloxone in cities across the state.
“How to Assemble a Nasal Naloxone (Narcan) Rescue Kit”
http://www.youtube.com/watch?v=Uq6AxrEY3Vk
(You must have internet access to view this 4
minute optional video.)
Summary
What we learned:
 Why Naloxone is an option for First
Responders & required for EMTs
 How to identify an opioid overdose
 Indications and contraindications
 Adverse reactions and management
 How an atomizer is prepared
 Intranasal administration
 Auto-Injector administration
Questions
What are the signs and symptoms of an
opioid overdose?
 What are the indications for Naloxone
administration?
 What are the contraindications to
administering Naloxone?
 What adverse reactions are possible with
Naloxone?
 How would you manage these reactions?

Skills Practical Assessment
Given a scenario by your instructor, demonstrate:
 Preparation of a naloxone atomizer using
required equipment
 Administration of intranasal naloxone on an adult
intubation manikin or skills trainer
 Administration of naloxone via auto-injector
using a auto-injector trainer
 Continued patient care & support
Final Details
Written Quiz
 Course Evaluation
 Roster
 Course Completion Document

References






Centers for Disease Control
Drugs.com
Federal Drug Administration
MacQuarrie, Brian (March 27, 2014)
Governor Declares an Emergency on Opiate
Abuse The Boston Globe
MDPH/Division of Research and
Epidemiology, Bureau of Health Information,
Statistics, Research, and Evaluation (2012) A
Decade of Mortality
Massachusetts: 2000-2009
References





MDPH Bureau of Substance Abuse Services
MDPH/OEMS, AR 2-100 Minimum Standards
for First Responder Training in First Aid,
Epinephrine Auto-Injector and Naloxone
Use (2014)
MDPH/OEMS EMS Pre-hospital Treatment
Protocols, 2014
MDPH/OEMS, Treat & Release; Patient
Refusals Advisory (2002)
N.O.M.A.D. (Not One More Anonymous
Death Overdose Prevention Project)
Credits
Special thanks to the following services and
individuals who shared their training materials
with the Region to help develop Version 1 of
this program:
 Boston EMS
 Fallon Ambulance
 Missy Fasshauer, Woods Ambulance
 Jerry Flanagan, Bound Tree Medical
 Joshua McCrillis, East Brookfield Fire
 Ken Ward, Vital EMS