1. Sierra – Sacramento Valley EMS Agency
BLS IN Naloxone Administration Optional Skill
(Updated 06/2017)
Acknowledgement: Siskiyou County SO - source of some slide content

2. In order for PSFA, EMR or EMT personnel to administer IN naloxone, they must:
Be part of the organized EMS system, functioning under the oversight of an S-SV EMS approved BLS optional skills provider
Be authorized by the approved BLS optional skills provider to administer IN naloxone
Have received adequate training on IN naloxone administration

3. Education/Training Purpose and Objectives
To enable authorized PSFA, EMR and EMT personnel to administer IN naloxone to patients in the prehospital setting
Objectives
Review background and causes of opioid overdoses
Identify signs and symptoms of an opioid overdose
Understand naloxone actions, indications, contraindications, dose, route, warnings and potential adverse reactions
Understand intranasal medication delivery
Describe/demonstrate treatment for suspected opioid overdose

4. Opioid Overdose Background & Causes
Identification of an Opioid Overdose
Naloxone Information
Intranasal (IN) Medication Administration

5. Opioid Overdose Background & Causes
About opioids
Sedative narcotics
Used primarily in medicine for pain relief
Induce euphoria – users feel warm, drowsy and content
Depressants – high levels can suppress the urge to breathe
Street opioids include heroin, street fentanyl, M-18, etc.
Prescription opioids included Hydrocodone/Norco, Oxycodone, morphine, fentanyl, etc.
Type, strength and consumption method influences to what degree and how long their effects last

6. Opioid Overdose Background & Causes
About opioids (cont.)
Other opioids of concern
Street fentanyl (“disguised” as Norco)
Carfentanil (elephant tranquilizer)
Analogue of fentanyl
100 times more potent than fentanyl
10,000 times more potent than morphine
Street fentanyl

7. Opioid Overdose Background & Causes
Opioid abuse is a major public health epidemic
16,325 prescription opioid-related deaths in the US in (4x the number of deaths that occurred in 1999)
8,257 deaths in the US from heroin in 2013
7,428 prescription opioid-related deaths in California from to 2012 (16.5% increase from 2006)
1,800 opioid-related deaths in California in 2012 alone (72% involved prescription pain medications)

8. Opioid Overdose Background & Causes
Efforts undertaken to combat the crisis
Calls to improve opioid prescription practices
Greater access to addiction treatment
Public naloxone distribution programs – 2015 California State Board of Pharmacy emergency regulations allow pharmacists to dispense naloxone without a prescription
Increased utilization of naloxone by BLS first responders

9. Opioid Overdose Background & Causes
About the solution
Abstinence from illegal drug use is the most effective overdose prevention tool
Most users attempt to achieve abstinence - on average this process takes 9 years/4 episodes of care to achieve success
Naloxone administration:
Temporarily reverses the effects of opioids
Only given when the patient is unresponsive and breathing ineffectively or not at all
Safe and effective – has no effect on non-opioid overdoses

10. Opioid Overdose Identification
Recognize
overdose
symptoms
Recognize drug paraphernalia
Recognize the drug
Recognition of need for naloxone administration
Look for physical signs and symptoms of overdose as well as drug paraphernalia and/or pill bottles
If in doubt or uncertain and patient is unresponsive with inadequate breathing – consider naloxone administration

11. Opioid Overdose Identification
REALLY HIGH
(NALOXONE NOT INDICATED)
OVERDOSE
(ADMINISTER NALOXONE)
Muscles become relaxed
Deep snoring or gurgling (death rattle)
Speech is slowed/slurred
Inadequate breathing (less than 12 breaths per minute) or not breathing
Sleepy looking
Pale, clammy skin
Nodding
Heavy nod
Will respond to stimulation like yelling, sternal rub, pinching, etc.
No response to stimulation

12. Naloxone Information Naloxone actions Naloxone onset and duration
Temporarily blocks the effects of opioids resulting in improved respiratory and neurological status
Naloxone onset and duration
Works in 1 – 3 minutes
Lasts up to 30 – 60 minutes
Naloxone contraindications
Known hypersensitivity (rare)

13. Naloxone Information Naloxone warnings
May induce opioid withdrawal in patients who are physically dependent
Certain drugs may require much higher naloxone doses
Naloxone potential adverse reactions
Rapid or irregular heart rate
High blood pressure
Nausea/vomiting
Diaphoresis (sweating)

14. Intranasal (IN) Medication Administration
IN administration
Uncomplicated and convenient
The nose is an easy access point for medication delivery
No shots required
Eliminates any risk of needle stick

15. Intranasal (IN) Medication Administration
IN administration (cont.)
The smelling area in the nose (olfactory mucosa) is in direct contact with the brain and CSF
Medications absorbed across the olfactory mucosa directly enter the CSF and provide a rapid/direct route for drug delivery to the brain
Olfactory mucosa
Nerve
CSF
Brain
Highly Vascular Nasal Mucosa

16. Intranasal (IN) Medication Administration
IN administration (cont.)
Bioavailability = how much medication ends up in the blood stream
Intravenous (IV) medications have 100% bioavailability
Oral medications have 5% - 10% bioavailability due to destruction in the gut and liver
Intranasal (IN) medications vary, but IN naloxone approaches 100% bioavailability (same as when given IV)
Naloxone IV and IN administration serum levels are identical after about 2 – 3 minutes

17. Intranasal (IN) Medication Administration
IN administration (cont.)
If there is something wrong with the nasal mucosa, it may not absorb IN administered medications effectively – examples:
Vasoconstrictors, such as cocaine, prevent medication absorption
Bloody nose, nasal congestion and/or mucous discharge may prevent medication absorption
Destruction of nasal mucosa (surgery, past cocaine abuse, etc.) results in no mucosa to absorb the medication

18. Treatment Of Suspected Opioid Overdose

19. Treatment Of Suspected Opioid Overdose
Ensure appropriate EMS units have been requested
Ensure scene safety
Utilize appropriate personal protective equipment (PPE)
Be aware of potential hazards
Needles
Hazardous materials
Bystanders, nearby traffic, etc.

20. Treatment Of Suspected Opioid Overdose
Assess patient
Stimulate – “shake and shout”
If pulseless, begin chest compressions
Assess/support respiratory status
Administer high flow O2 (if available)
If no response to stimulation and continued poor/absent breathing, administer intranasal (IN) naloxone

21. Treatment Of Suspected Opioid Overdose
Naloxone 2 mg preloaded syringe with mucosal atomizer device (MAD)
Administer ½ dose in each nostril when patient exhales and before inhalation

22. Treatment Of Suspected Opioid Overdose
NARCAN® Nasal Spray 4 mg
If using this type, all medication can be administered in one nostril
Administer when patient exhales and before inhalation

23. Treatment Of Suspected Opioid Overdose
Additional treatment notes:
Observe for improved breathing/consciousness, if no improvement assist breathing with BVM (if available) or begin CPR if appropriate
If CPR is not necessary and it is possible, place patient in recovery position to avoid potential for inhaling any vomit
Consider additional doses of naloxone if necessary and available

24. Treatment Of Suspected Opioid Overdose
Additional treatment notes (cont.)
Use naloxone with caution in patients with significant trauma who have not been adequately immobilized
Consider the concurrent need for appropriate immobilization/spinal motion restriction
Although rare, be alert for sudden agitated/violent behavior
Because naloxone stops the effects of opioids, an opioid dependent person may experience acute withdrawal symptoms

25. Treatment Of Suspected Opioid Overdose
Other responsibilities
Inform other appropriate EMS providers and/or the receiving hospital of any pertinent details related to the naloxone administration
Adequately document the naloxone administration for reporting and QI review requirements

26. Treatment Of Suspected Opioid Overdose
Keep in mind
Naloxone is only for unconscious patients with inadequate breathing or not breathing at all
Do not use prophylactically or for individuals who are simply under the influence without respiratory depression
Naloxone only treats the effects of opioids
If no opioids are present, there is no effect from administering naloxone
Naloxone will not treat the effects of alcohol, cocaine, or other substances