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Sierra – Sacramento Valley EMS Agency BLS IN NALOXONE ADMINISTRATION OPTIONAL SKILL (UPDATED 06/2017) Acknowledgement: Siskiyou County SO - source of some slide content
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
• 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
Education/Training Purpose and Objectives
• Opioid Overdose
Background & Causes
• Identification of an Opioid
Overdose
• Naloxone Information
• Intranasal (IN) Medication
Administration
• 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 Background & Causes
Recognition of need for naloxone administration
Opioid Overdose Identification
Recognize overdose
symptoms
Recognize the drug
Recognize drug
paraphernalia
• 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 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)
Naloxone Information
• 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
Intranasal (IN) Medication Administration
Olfactory mucosa
Brain
Nerve CSF
Highly Vascular Nasal Mucosa
• 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
Intranasal (IN) Medication Administration
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 O2 (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
Treatment Of Suspected Opioid Overdose
o Consider additional
doses of naloxone if
necessary and
available
• 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
Treatment Of Suspected Opioid Overdose
