2. Naloxone Administration
So what changed?
EMSWorld (Understanding Overdose)
SAMHSA 5 Steps to overdose response / OverdoseToolkit
Let’s watch a video!
Review Updated‘Altered Mental Status’ Protocol
3. Update to NYS Policy
The SEMAC has approved an amendment to theAltered Mental Status protocol in the NewYork State
CFR and EMT/AEMT BLS Protocols which will enable EMS agencies and certified Basic Life Support
EMS providers to administer intranasal naloxone to patients experiencing an acute opioid overdose.A
NYS EMS Lesson Plan Guide has been developed for use by EMS course sponsors.Additionally, the
REMAC may approve training programs and determine the type and level of record keeping and quality
assurance requirements for this procedure.
4. NY Policy responds to growing problem
In 2009, 91% of unintentional poisoning deaths caused by prescription meds.
Opioid pain meds and benzodiazepines were most common.
Prescription painkiller overdoses were responsible for more than 15,500
deaths in 2009, more than the total for cocaine and heroin combined.
almost four times greater than the 4,000 people killed in 1999.
Methadone has played a central role.
More than 30% of prescription painkiller deaths involve it, even though only 2% of
painkiller prescriptions are for it.
More than 12 millionAmericans reported using prescription painkillers for
nonmedical reasons in 2012.
5. NY Policy responds to growing problem
more than three-fourths of
involved in overdoses come
from prescriptions diverted
to persons without them
majority of misused
(55%) are obtained for free
from friends or relatives
6. NY Policy responds to growing problem
Groups susceptible to unintentional overdose of prescription
Men are twice as likely to die as women.
Middle-aged adults have the highest overdose rates.
Persons living in rural counties are nearly twice as likely to
overdose as those living in urban areas.
Whites, Native Americans andAlaska natives are more likely to
About 1 in 10 NativeAmerican orAlaska natives 12 or older used
prescription painkillers for nonmedical reasons in the past year,
compared to 1 in 20 whites and 1 in 30African-Americans.
7. Opioid Toxidromes
toxidrome is a group of signs and symptoms characteristic of an
exposure to a specific substance or class of substances
classic toxidrome associated opioid toxicity is CNS depression,
respiratory depression and miosis (constricted pupils).
Additional signs and symptoms include GI symptoms like nausea
and vomiting, decreased motility, ileus; cardiac symptoms
including bradycardia and hypotension; and respiratory
symptoms including acute lung injury and pulmonary edema,
plus respiratory arrest
8. Opioid Toxidromes
Respiratory depression is characterized by breathing that is both
slow (bradypnea) and shallow (hypopnea).
Opioids decrease respiratory drive by suppressing the sensitivity of
the respiratory centers in the medulla oblongata.
While miosis is considered a classic finding associated with opioid
overdose, there are factors that can prevent it from occurring.
Not all opioids will produce miosis,
not typically seen with meperidine (Demerol), pentazocine (Talwin) or
propoxyphene (Darvon, Darvocet).
In addition, the coingestion of another drug can alter the clinical
presentation of the patient with an opioid overdose.
About half of prescription painkiller deaths involve at least one other
drug (benzodiazepines, cocaine, heroin), and alcohol is a component
in many overdose deaths.
9. Opioid Overdose What to look for…..
Obtain an accurate and thorough patient history from bystanders,
family members, friends or the patient, if they are alert, oriented and
Pertinent aspects of the history include:
Does the patient have a history of opioid abuse, either via
prescription medications or illicit drugs? Is there a history of substance
abuse? Is there a history of suicide attempt?
Does the patient have access to opioid painkillers? Does the patient
have chronic pain/recent surgery/cancer that could predispose them to
accidental overdose?Are they prescribed painkiller medication, or does
anyone in the home have a prescription? Does a friend or family member
outside the home have a prescription?
10. Opioid Overdose What to look for…..
Are prescription medication bottles present on scene?What are the
medications? Do the bottles actually contain the medications listed on
them?To whom are they prescribed?Are there pills missing?
Does the patient have any pills on their person or in personal
items such as their purse or backpack? Has an attempt been made to
identify unknown pills or tablets? (Remember to bring all pill bottles to
What was the time of ingestion? How much was ingested?Were other
medications or alcohol also ingested?
Has the patient vomited?Were there pills in the vomit?
11. SAMHSA Opioid Overdose Toolkit
SubstanceAbuse and Mental Health ServicesAdministration
Five Essential Steps for First Responders
Referenced as training from BEMS as part of Protocol Update
Overdose is common among persons who use illicit opioids such as heroin
and among those who misuse medications prescribed for pain, such as
oxycodone, hydrocodone, and morphine.
Incidence of opioid overdose is rising nationwide.
Between 2001-2010, the number of poisoning deaths in the United States nearly
doubled, largely because of overdoses involving prescription opioid analgesics.
This increase coincided with a nearly fourfold increase in the use of
prescribed opioids for the treatment of pain.
12. SAMHSA Opioid Overdose Toolkit
STEP 1: Call for Help (Dial 911)
STEP 2: Check for signs of Opioid Overdose
Signs of OVERDOSE
Face is extremely pale and/or clammy to the touch
Body is limp
Fingernails or lips have a blue or purple cast
The patient is vomiting or making gurgling noises
He or she cannot be awakened from sleep or is unable to speak
Breathing is very slow or stopped
Heartbeat is very slow or stopped
13. SAMHSA Opioid Overdose Toolkit
STEP 2 (Cont’d): Check for signs of Opioid Overdose
Signs of OVER MEDICATION that can lead to overdose
Unusual sleepiness or drowsiness
Mental confusion, slurred speech, intoxicated behavior
Slow or shallow breathing
Pinpoint pupils (not always*)
Slow heartbeat, low blood pressure
Difficulty waking the person from sleep
14. SAMHSA Opioid Overdose Toolkit
STEP 3: Support Breathing
100% O2 and/or Rescue breathing
Every Unconscious Patient gets an……
STEP 4:Administer Naloxone
See Protocol later
STEP 5: Monitor Response
Most patients respond by returning to spontaneous breathing, with
minimal withdrawal symptoms
15. SAMHSA Opioid Overdose Toolkit
The response generally occurs within 3 to 5 minutes.
Rescue breathing should continue while waiting for the naloxone to take effect.
Naloxone will continue to work for 30 to 90 minutes, but after that
time, overdose symptoms may return.
Therefore, it is essential to get the person to an emergency department or other
source of medical care as quickly as possible, even if he or she revives after the
initial dose of naloxone and seems to feel better.
16. SAMHSA Do’s and Don’ts
DO support the person’s breathing by administering oxygen
or performing rescue breathing.
DO administer naloxone.
DO put the person in the “recovery position” on their side, if
he or she is breathing independently.
DO stay with the person and keep him/ her warm.
17. SAMHSA Do’s and Don’ts
DON'T slap or try to forcefully stimulate the person — it will only cause
further injury. If you are unable to wake the person by shouting, rubbing
your knuckles on the sternum (center of the chest or rib cage), or light
pinching, he or she may be unconscious.
DON'T put the person into a cold bath or shower.This increases the risk of
falling, drowning or going into shock.
DON'T inject the person with any substance (salt water, milk,“speed,”
heroin, etc.).The only safe and appropriate treatment is naloxone.
DON'T try to make the person vomit drugs that he or she may have
swallowed. Choking or inhaling vomit into the lungs can cause a fatal