Category Archives: Opioid Toxicity

My question is can you TOR an opioid overdose cardiac arrest. The question came up recently and it seemed a simple yes because opioid overdose cardiac arrests are to be run as a standard medical arrest. However, some people have referenced the "very early transport after one analysis... for medication overdose/ toxicology." This is further confused by the 1-Mar-2012 Ask MAC submission where it was stated you could not obtain a TOR on an OD (but did not specify what type of OD). I am hoping you can provide some clarification on obtaining a TOR during an opioid overdose VSA.

Question: Could you please give clarification - On a VSA of a suspected opioid overdose, can we leave after the 1st analysis? Half my co-workers say yes and the other half says no, that you must stay to complete 4 analysis. I understand that early transport can be considered in medication overdose/toxicology. Where we are having difficulty with the interpretation of the protocol is "In cardiac arrest associated with opioid overdose, continue standard medical cardiac arrest directive. There is no clear role for routine administration of naloxone in confirmed cardiac arrest". Some medics are saying that the "continue standard medical arrest directive " means to complete 4 analysis. My interpretation is, no narcan and continue protocol, which is to consider early departure. Thanks

*UPDATED* Question: Regarding the removal of "inability to ventilate" consideration for narcan. In a pt who fails the covid screening, and who has overdosed on opiates, spontaneous resp rate <8, low says. Are we to withhold BVM and apply hi-flo mask at 8L and give narcan? Or use BVM as usual to assist ventilations prior to narcan administration. Its the use of the BVM in this pt that is the question

As PCPs are we allowed diluting Narcan 0.4mg/ml 1:9 with NS when giving it IV route? (0.04mg/10ml) titrate to effect.

Question: The Opioid Medical Directive allows for Naloxone to be administered 0.8mg SC/IM/IN and 0.4mg IV. The IV route allows the paramedic to titrate to restore the patient's respiratory status. Can this titration also be applied to the SC/IM/IN?

Question: My question relates to narcan. Do you feel it is necessary in all cases to check BGL prior to administering narcan? The Medical Directive reads uncorrected hypoglycemia as contraindication but in the presence of no diabetic history and an incident history which is clearly indicating opioid overdose combined with critically low oxygen saturation and no ability to ventilate are we to invariably to take a BGL prior to treating obvious signs and symptoms of opioid overdose or can we use clinical judgement based on findings? It goes without saying that a BGL should eventually be taken on such a patient at some point but my question is with a critical patient, no history or finding consistent with low BGL and multiple indicators for OD are we not safe to presume OD, treat accordingly and follow up with BGL afterwards to rule out hypoglycemia?

Question: I have a question regarding the administration of narcan. Narcan seems to be given more often now that there is no patch point. The wording of the medical directive hasn't changed though so just to confirm, are we still just to be giving it when we cannot adequately ventilate the patient? Example, if they are GCS of 3 and breathing inadequately but we are getting good compliance on the BVM and the patient’s vitals are otherwise stable, are we ok to not give it? If we do go ahead and give narcan to a patient who is NOT breathing and they start breathing on their own but are still GCS of 3 are we to stop there since we can now manage their airway or do we continue up to our maximum of 3 doses or until they become GCS of 15?

Question: What is the rationale for the 18 years old and greater age for naloxone administration? (i.e. legal, risk factors?)

Question: We have been trained on the Opioid Toxicity Medical Directive and the educators reiterated to use it as a last resort because of the potential for violence. I understand their concerns. I also appreciate these kits are out in the public for use and our skill set should continue to exceed that of the layperson(s). However, I wonder why not consider expanding the king LT insertion medical directive to include GCS = 3 for PCPs? This would allow safe and effective airway management of suspected overdose patients (or other GCS = 3 patients), even in situations of long transport times. We already preform this task in situations where a ROSC is obtained. We are familiar and proficient with the equipment and there is no additional cost to the services.

Question: On February 21, of this year the London Free Press had an article stating that the Middlesex London Health Unit plans to roll out naloxone kits to the public in hopes of preventing deaths from unintentional overdoses. Toronto Health Unit has already been distributing these kits. Why are Primary Care Paramedics still without this drug when Naloxone now in the hand of the public?

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