by Case: 16yr old female (about 55kg) came in to the ED as toxic ingestion of opiates, stating that she took percocets and hydromorphone pills her parents had in the house. As the team was managing the case, 6 hours into observation they noted that she was becoming increasingly lethargic, they noted she would maintain her ventilation although noted EtCO2 of low-mid 40s (nml 35-45 mm Hg) with two periods of apnea where she would desaturate down to 86%. All labs (including tylenol level taken at 4hr from ingestion) were within normal limits (urine tox opiate and oxycodone positive), and she would remain fully alert if she was having a conversation or would awaken to her name being called.
The decision was made to give her narcan, 0.4mg IVP About 2 minutes s/p narcan administration…
Out of all the narcans I’ve given at Coney, i had never seen someone be pushed that quickly into withdrawal and vomit.
These questions popped into my head: Should the team have given a pediatric dose? Was she actually opiate-dependent when history says this was the first time (patients ALWAYS lie)? Was the Narcan appropriate at that time? What could have been done to prevent the pukey pukey?
Review
Narcan dosage:
Adults: (may repeat q3min with max dose 10mg)
- -Apneic/Near-Apneic = 2mg IV
- -Opioid-naive with minimal respiratory depression = 0.4mg IV
- -Opioid-dependent with minimal respiratory depression = 0.05mg IV
Pediatrics: (if no IV route available give IM)
-0.005 to 0.01mg/kg IV (repeat q2-3min until desired effect)
–> (pt was 55kg so the upper limit of the dose would have been 0.55mg)
NARCAN Onset of action: 1-2 min Duration: 20-90 min
HYDROMORPHONE Onset of action 30-60min
Lesson Learned:
Start with the smaller dose (in adults 0.04mg and in peds 0.005mg/kg) and then titrate up in the next dose administration
EMRAP’s Push Dose Narcan:
How much should you give? LaPoint gives 0.01mg every few minutes. A vial has 0.4mg/ml. Take 0.25mL, which is 0.1mg. Dilute it into 10cc of saline. This gives you ten doses of 0.01mg. However, you may need a higher amount for some of the more potent opiates such as fentanyl or carfentanil. If the patient is peri-arrest, it is not unreasonable to give a larger dose.
-worse things could have happened to this young girl with previous reports of Vfib, Vtachy, seizures or flash pulm edema noted in some of the references
Always watch the EtCO2 and have that factor into when you should or should not give Narcan -her periods of apnea and desaturation were the most concerning here
In this case, I wish the team would have Nebulized the Narcan
-Maybe the slow administration via nebs could have prevented the vomiting
-Maybe a few minutes of nebulized narcan is all she really needed since she was kind of on the fence of to give or to continually stimulate
How To: 1-2 mg naloxone in a total volume of 3-5 mL saline in nebulized mask
(peds dosing unavailable but a 0.4mg dose in 3-5mL of saline sounds pretty good to me)
References:
- https://wikem.org/wiki/Naloxone
- http://www.emdocs.net/tox-cards-narcan-naloxone/
- https://www.emrap.org/episode/redhotandshot/naloxone https://www.aliem.com/2011/11/trick-of-the-trade-nebulized-naloxone/
