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Ct ems naloxone_bls_training_27may2014 PPT


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2015 Initial Training

Published in: Government & Nonprofit
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Ct ems naloxone_bls_training_27may2014 PPT

  1. 1. NaloxoneNaloxone Training ProgramTraining Program EMR/EMTEMR/EMT May 27, 2014May 27, 2014 State of Connecticut Department of Public Health/OEMS 1
  2. 2. GoalGoal To reduce mortality and morbidity from opioid overdose by instructing EMS Responders (EMT and EMR) in the administration of naloxone. 2
  3. 3. ObjectivesObjectives By the end of this course the EMT/EMR will: •Recognize the signs and symptoms of an opiate overdose •Identify the indications and contraindications of naloxone •Explain the possible adverse reactions of naloxone •Describe how to manage adverse reactions •Prepare and administer naloxone via approved route •Describe the on-going patient management after the administration of naloxone •Appreciate the place of naloxone in the management of opioid overdose 3
  4. 4. HistoryHistory • In 2010, approximately 38, 329 drug overdose deaths occurred in the United States, one death every 7 minutes. • About 75% of these deaths involved prescription opioid analgesics. • In 2009 alone, there were 257 million opioid prescriptions written. 4
  5. 5. Rate* of unintentional drugRate* of unintentional drug OD deaths US 1970–2007OD deaths US 1970–2007 * Per 100,000 population 5
  6. 6. Treatment HistoryTreatment History • Opiates kill because they cause people to stop breathing • EMTs and EMRs have been limited to providing ventilatory support as a means to reverse hypoxia • Reversal of the cause of hypoventilation allows for return of spontaneous respiration and limits the continued need for ventilatory support • Prolonged hypoventilation complications include hypercarbia, hypoxia, aspiration, respiratory arrest and death 6
  7. 7. Naloxone (NarcanNaloxone (Narcan®® )) • Naloxone (Narcan® ) is an opioid (narcotic) antagonist that may 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. 7
  8. 8. CAUTION!!CAUTION!! • Naloxone works for a shorter period of time than most opioids • Without additional treatment, patients may experience a relapse of respiratory arrest that may lead to death 8
  9. 9. OpioidsOpioids Synthetic or semi-synthetic alkaloids act on the Central Nervous System as a depressant 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) May be abused to induce euphoria or “high” 9
  10. 10. Opioids, continuedOpioids, continued • Tolerance and/or addiction may occur, requiring increasing doses for the same effect • Common side effects include: -respiratory depression -drowsiness -itching -nausea and vomiting -dry mouth -miosis (constricted pupils) -constipation 10
  11. 11. OpioidsOpioids Opioids may include: Buprenorphine Butorphanol (Stadol® ) Codeine Fentanyl (Duragesic® patch) Hydrocodone (Vicodin® ) Hydromorphone (Dilaudid® ) Meperidine (Demerol® ) Methadone Morphine Nalbuphine (Nubain® ) Oxycodone (Percocet® /Percodan® ) Oxymorphone Pentazocine (Talwin® ) Paregoric Propoxyphene (Darvon® ) 11
  12. 12. OpioidsOpioids 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 12
  13. 13. Opioid AddictionOpioid Addiction Treatment DrugsTreatment 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”) 13
  14. 14. Target PopulationTarget Population The target population for naloxone is persons who may have overdosed on opioids and whose respiratory drive is at a depressed life- threatening level. 14
  15. 15. On SceneOn Scene • You may know you’re responding to a suspected overdose, or you may be told upon arrival • Scene Safety/BSI is a top priority • Do you have appropriate resources present or responding? • Remain non-judgmental and non-confrontational • Ask bystander(s) what and when the patient injected, ingested, or inhaled (or if a transdermal patch has been used) • Was more than one substance used? 15
  16. 16. On SceneOn Scene •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 Drug use clues 16
  17. 17. On SceneOn Scene Drug Kit “Packaged” Drugs (Heroin) Drug use clues 17
  18. 18. On SceneOn Scene Drug use clues “Track Marks” 18
  19. 19. Signs and Symptoms ofSigns and Symptoms of Opioid/Toxidrome:Opioid/Toxidrome: • Unresponsive or minimally responsive, with a pulse • Depressed respiratory rate • Agonal respirations • Respiratory arrest • Cyanosis • Miosis (constricted pupils) 19
  20. 20. Indications for Naloxone UseIndications for Naloxone Use •Respiratory arrest or hypoventilation in addition to: •Evidence of opioid/opiate use • Bystander report • Drug paraphernalia • Opioid prescription bottles/patches • “Track marks” • Opiate/opioid toxidrome 20
  21. 21. “Addicts take opiates and other sedatives specifically to induce a pleasant stupor. If they’re lethargic and hard to arouse, but still breathing effectively, it’s not an overdose. It’s a dose.” –Boston paramedic 21 • Naloxone is for depressed respirations, not depressed mental status. • Opiate use alone (without depressed respirations) does not merit the use of naloxone.
  22. 22. ContraindicationsContraindications Known hypersensitivity (rare) 22
  23. 23. Naloxone DosageNaloxone Dosage • Naloxone dosage will be specified by the agency’s EMS sponsor hospital • Common intramuscular (IM) dosage: o 0.4 mg autoinjector • Common intranasal (IN) dosage: o Adults and children: 2 mg (2 mL) divided as 1mg (1 mL) per nostril o Infant and toddler: naloxone 1 (1 mL) mg divided as 0.5 mg (0.5 mL) per nostril • Physician oversight may direct different dosing to improve therapy or decrease adverse effects 23
  24. 24. Naloxone UseNaloxone Use • Ensure scene safety! • Maintain appropriate Body Substance Isolation (BSI) • Assess level of consciousness and vital signs • Maintain open airway and provide tactile stimulation • Assist ventilations • Ensure appropriate resources are responding • Administer naloxone when indicated • Initiate transport as soon as possible (don’t wait on scene for paramedic) 24
  25. 25. Naloxone Use,Naloxone Use, continuedcontinued The “Eight Rights” for Medication Administration: •Right Patient •Right Reason •Right Time •Right Dose •Right Route •Right Drug •Right Response •Right Documentation 25
  26. 26. • Administer naloxone via approved route at specified dose • Continue ventilating patient as needed • Consider contacting poison control if poly- substance use is suspected: (800) 222-1222 26 Naloxone Use,Naloxone Use, continuedcontinued
  27. 27. Naloxone Use,Naloxone Use, continuedcontinued • The effects of naloxone may not last as long as the effects of the opioid; be prepared for a return of overdose signs & symptoms! • Every effort should be made to encourage patient be transported to definitive care. • Physician or police speaking with the patient may assist in eliciting transport. 27
  28. 28. Methods of AdministrationMethods of Administration • The following slides address the preparation and administration of both intranasal and intramuscular (via autoinjector) administration of naloxone. • Providers may only administer naloxone via the route(s) authorized by their EMS sponsor hospital. 28
  29. 29. Intranasal NaloxoneIntranasal Naloxone • 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 Avoid temperature extremes 29
  30. 30. Why Intranasal?Why Intranasal? Works almost as quickly as IV route since nasal mucosa is highly vascularized and absorbs drugs directly into the blood stream 30
  31. 31. Why an Atomizer?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. 31
  32. 32. Intranasal NaloxoneIntranasal Naloxone Preparation Step 1Preparation Step 1 You will need: •One Luer-Jet needle-free syringe •One ampule of naloxone 2.0 mg •One atomizer Dosage indicator 32
  33. 33. Intranasal NaloxoneIntranasal Naloxone Preparation Step 2Preparation Step 2 Remove the caps from both ends of the Luer-Jet needle-free syringe 33
  34. 34. Intranasal NaloxoneIntranasal Naloxone Preparation Step 3Preparation Step 3 Remove the red cap from the naloxone vial Screw the now open end of the vial into the syringe, it will become difficult to turn when it is threaded enough 34
  35. 35. Intranasal NaloxoneIntranasal Naloxone Preparation Step 4Preparation Step 4 Attach the nasal atomizer to the opposite end. 35
  36. 36. One Luer-Attached AtomizerOne Luer-Attached Atomizer 36
  37. 37. Intranasal NaloxoneIntranasal Naloxone AdministrationAdministration •Ventilate patient with BVM •Assess the patient to ensure their nasal cavity is free of blood or mucous (suction if needed) •Control patient’s head with one hand •Gently but firmly place atomizer within one nostril, carefully occluding the opposite nostril 37
  38. 38. Intranasal NaloxoneIntranasal Naloxone Administration,Administration, continuedcontinued •Aim slightly upwards and toward ear on same side as the nostril •Briskly compress syringe to administer ½ of total dose (up to 1.0 mg of atomized spray per local medical control) •Repeat in other nostril (using both nostrils doubles the surface area available for absorption) •Continue ventilating patient with BVM 38
  39. 39. Intramuscular NaloxoneIntramuscular Naloxone 39
  40. 40. Why Intramuscular?Why Intramuscular? • Consistent delivery of medication • Simple and fast acting • Similar to other auto-injectors used by EMS 40
  41. 41. Intramuscular NaloxoneIntramuscular Naloxone AdministrationAdministration • Ventilate patient with BVM • Pull naloxone auto-injector from case o Device will now provide voice- prompt guidance • Grasp firmly and pull off red safety guard 41
  42. 42. Intramuscular Naloxone AdministrationIntramuscular Naloxone Administration, continued, continued • Place black end against patient’s outer thigh • Press firmly against patient’s outer thigh and hold in place for five seconds. • Remove auto-injector and dispose of in sharps container • Continue to ventilate patient with BVM 42
  43. 43. Critical ReminderCritical Reminder • Do NOT get distracted by drug administration • Be sure to ventilate properly as needed 43
  44. 44. Avoid “Tunnel Vision”Avoid “Tunnel Vision” • If respirations do not improve after five minutes, consider what else could be going on? 44
  45. 45. Other PossibilitiesOther 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? 45
  46. 46. Adverse ReactionsAdverse Reactions • Use caution when administering naloxone to narcotic dependent patients! • Rapid opiate withdrawal may cause nausea & vomiting. • Keep airway clear and be prepared to suction! 46
  47. 47. Adverse Reactions,Adverse Reactions, continuedcontinued Rapid opiate withdrawal may also cause: •Runny nose •Diaphoresis (excessive sweating) •Tachycardia •Tremulousness •Hypertension (high blood pressure) •Hypotension •Cardiac disturbances, including cardiac arrest •Epistaxis 47
  48. 48. Adverse Reactions,Adverse Reactions, continuedcontinued 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 48
  49. 49. Paramedic RoleParamedic Role • Call for Paramedic if available • Paramedic may titrate naloxone dosing to reverse respiratory depression without full return to consciousness • Patient may require care for: o Other medications/drugs they have received (polypharmacia) o Additional care if no response to BLS care or if patient relapses o Other conditions (head Injury, stroke, hypoxia, etc.) • Do not delay transport 49
  50. 50. DocumentationDocumentation As always, carefully document, including: •Patient presentation (neuro, respiratory, cardiac) •Signs and symptoms (before & after treatment) •Vital signs (before & after treatment) •naloxone administration prior to EMS arrival •Clinical response •Any use of physical restraint •Record time drug was administrated, amount, and route, for example: “19:21, naloxone 2.0 mg intranasal” “02:32, naloxone 2.0 mg intramuscular (IM), right thigh” 50
  51. 51. Patient RefusalsPatient 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 further care • Having a physician speak with the patient may assist in encouraging transport. • Request police assistance if needed 51
  52. 52. NotesNotes • Continue to provide respiratory assistance as needed. • If no pulse, with or without agonal breathing, begin CPR. • Do not administer naloxone to patients in cardiac arrest. • If respirations adequate, provide supportive care. • Naloxone is not effective against overdose from non-opiate drugs. • Review your Sponsor Hospital Policies and Procedures. 52
  53. 53. ReviewReview What have we learned: •Why naloxone was added as an option for BLS. •What an opioid overdose presents like. •What the signs and symptoms of an opioid overdose are. •The indications for administering naloxone. •The contraindications to administering naloxone. •The possible adverse reactions of naloxone. •How to manage adverse reactions. •How to prepare a naloxone atomizer or to administer naloxone via autoinjector. 53
  54. 54. Thank youThank you Special thanks to those who have shared their training materials with us to help develop this program: • To Central Massachusetts EMS for use of much of their BLS naloxone program and slides •Peter Canning RN, Paramedic, EMS Coordinator at John Dempsey Hospital •State of CT EMS Advisory Board, Education and Training Committee 54
  55. 55. ReferencesReferences • Centers for Disease Control • • Federal Drug Administration • CT DPH Bureau of Substance Abuse Services • N.O.M.A.D. (Not One More Anonymous Death Overdose Prevention Project) 55
  56. 56. Skills Practice &Skills Practice & AssessmentAssessment Given a scenario by your instructor: •Prepare a naloxone atomizer and/or autoinjector using the required equipment •Demonstrate administration of intranasal and/or intramuscular naloxone on an adult manikin •Demonstrate as well as explain how you will provide continued patient care support 56
  57. 57. Student EvaluationStudent Evaluation 57