Dr. Youn presents today’s edition of Morning Report!
NEBULIZED NALOXONE
- Weber, et al. Prehosp Emerg Care,
- 2mg naloxone nebulized with 3mL normal saline
- 105 cases- 22% complete response, 59% partial response, 19% no response
- No adverse events, no intubations or BVM ventilations
- Only 10% were given a second dose of naloxone
- Unclear how response was determined (likely subjective)
- Baumann et al. Am J Emerg Med, 2013
- Observational study of 26 patients (out of 54) in an urban ED setting
- Route of administration based on physician discretion. Opioid intoxication was defined a priori as any patient who arrived in the ED with either a depressed sensorium or respiratory drive and a history of opioid use as provided by either the patient or prehospital
- Minimum RR was 6 to be included
- Pts received 2mg in 3mL NS.
- Median GCS scores improved from 11 to 13, median RASS scores improved from -3.0 to -2.0, and need for supplemental O2 decreased from 81% to 50%.
- Eleven of the 26 required a second dose of medication, and three of those eleven went on to require a third dose.
- 12% reported moderate-to-severe agitation.
TAKE HOME:
- Naloxone indicated in presumed/confirmed opiate overdose with RR < 12
- 1-2mg in 3-5mL NS
- Needle-less, steady low-maintenance dose
- Self-titrating because when patient awakens, he/she will pull off the mask, but requires a spontaneously breathing patient
- Half-life of naloxone approx. 1 hour; opioid half-line depends on agent
- Be mindful of causing withdrawal
- Can always escalate treatment to IN/IM/SQ/IV formulations
- Naloxone drip: hourly infusion rate calculated as 2/3rds of the total bolus dose given to achieve the desired opioid reversal effect
REFERENCES:
Baumann BM, Patterson RA, Parone DA, et al. Use and efficacy of nebulized naloxone in patients with suspected opioid intoxication. Am J Emerg Med. 2013; 31: 585-588.
Mycyk MB, Szyszko AL, Aks SE. Nebulized naloxone gently and effectively reverses methadone intoxication. J Emerg Med. 2003 Feb;24(2):185-7.
Weber JM, et al. Can nebulized naloxone be used safely and effectively by emergency medical services for suspected opioid overdose? Prehosp Emerg Care. 2012 Apr-Jun;16(2): 289-292.
Academic Life in EM. Trick of the trade: nebulized naloxone. http://academiclifeinem.com/trick-of-the-trade-nebulized-naloxone/ Accessed November 29, 2014.
The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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Jay Khadpe MD
Editor in Chief of "The Original Kings of County"
Assistant Professor of Emergency Medicine
Assistant Residency Director
SUNY Downstate / Kings County Hospital
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