INTRANASAL NALOXONE

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Education and Training Module for Ohio EMS INTRANASAL NALOXONE

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INTRANASAL NALOXONE. Education and Training Module f or Ohio EMS. NALOXONE ( Narcan ®). Developed in the 1960s Opioid antagonist Emergent overdose treatment in the hospital and prehospital settings Increased demand for naloxone - Greater variety of available opioids - PowerPoint PPT Presentation

Transcript of INTRANASAL NALOXONE

INTRANASAL NALOXONE

Education and Training Module for Ohio EMSINTRANASAL NALOXONE

Welcome to the intranasal naloxone education and training module for Ohio EMS! On October 16, 2013, the Emergency Medical, Fire, and Transportation Services Board amended of the Ohio EMS scope of practice for intranasal naloxone administration. The Board expanded the scope of practice to allow emergency medical responders and emergency medical technicians, upon completion of training and with the approval of the medical director, to administer intranasal naloxone to a person suspected of suffering from an opioid overdose. The Ohio Department of Public Safety, Division of EMS is pleased to provide this education and training module on intranasal naloxone administration for all Ohio EMS providers, EMS medical directors, and EMS education institutions.1Developed in the 1960sOpioid antagonistEmergent overdose treatment in the hospital and prehospital settingsIncreased demand for naloxone - Greater variety of available opioids - Increased opioid use and abuse NALOXONE (Narcan)

The use and abuse of opioids has existed in our society for centuries. Naloxone is an opioid antagonist and its primary use is for the emergent treatment of opioid overdoses. Naloxone was developed in the 1960s during a period in our nation where experimentation with and abuse of opioids became more widespread and less secretive. The demand for naloxone has grown significantly due to a greater variety of types of opioids legally prescribed for patient use and those that are available illegally2BuprenorphineCodeineFentanylHydrocodoneFrequently Prescribed OpioidsHydromorphoneMethadoneMorphineOxycodone

This is a list of the legal opioids that are frequently prescribed to patients for pain relief. They are approved for patient care by the FDA.3Frequently Prescribed Combination Opioid MedicationsLorcet, Lortab, Norco, Vicodan: Hydrocodone + acetaminophenPercocet: Oxycodone + acetaminophenPercodan: Oxycodone + aspirinSuboxone: Buprenorphine + naloxoneOpiumHeroinIllegal opioids

Opioids for pain relief are often combined with other pain relieving medications by manufacturers. Some of them are listed here. When providing care for a patient who has taken one of these combination medications, it is important for EMS providers to consider the potential toxicity of the other components of the medication. For example, acetaminophen in large doses can cause significant damage to the liver and an antidote is available. The most common illegal opioids in the world are opium and heroin. Opium, which is derived from the opium poppy, is refined to make both legal and illegal opioids. Illegal opioids are also often combined with other drugs such as cocaine, LSD, or PCP. Recently, heroin abuse has had a major reappearance within our society and is causing an increased demand for naloxone.4OralTranscutaneousIntravenousSubcutaneous (skin popping during the abuse of opioids)Routes of Administration of Opioids by Laypersons

There are three primary routes of opioid administration for laypersons: Oral, transcutaneous in the form of an adhesive medication patch, and intravenous in patients who are discharged from health care facilities with IV access left in place. Although some opioids are approved for subcutaneous administration, this route is almost exclusively used by drug abusers with poor veins.5Miosis (pinpoint pupils)Decreased intestinal motilityRespiratory depressionDecreased mental status

Signs and Symptoms of an Opioid Overdose

The primary signs and symptoms of an opioid overdose are pinpoint pupils, respiratory depression, and decreased mental status or unresponsiveness. Chronic opioid use can cause constipation, but even short-term use will decrease intestinal motility, the movement of food through the gut.6HypoxiaHypercarbiaAspirationCardiopulmonary arrestThe incidence of risk factors increases when other substances such as alcohol, benzodiazepines, or other medications have also been taken by the patientRisk Factors with Opioid Overdose

The risk factors associated with opioid overdose include hypoxia or hypercarbia from respiratory depression, aspiration, and cardiopulmonary arrest. Alcohol or benzodiazepines, when combined with opioids, increase the risk all of these.7Physiology of NaloxoneNaloxone displaces the opioid from the opioid receptor in the nervous systemOpioid receptorOpioidNaloxone

Naloxone works by displacing the opioid in the nervous system and bonding to the opioid receptors.8Physiology of NaloxoneThis may result in the sudden onset of the signs and symptoms of opioid withdrawal

AgitationTachycardiaPulmonary edemaNauseaVomitingSeizures

The blockade of the opioid receptors by naloxone suddenly stops the effects of the opioid on the nervous system. This may cause the sudden onset of signs and symptoms of opiate withdrawal. These symptoms include agitation, tachycardia, pulmonary edema, nausea, vomiting, and seizures.9EndotrachealIntramuscularIntranasalIntravenousRoutes of Administration of Naloxone

For EMS providers, the traditional routes of administration of naloxone are via an endotracheal tube, intramuscular, intranasal, and intravenous.

10Equivalent clinical efficacy compared to intravenous naloxoneIntravenous access may be impossible to establish in chronic intravenous drug abusersBenefits of Intranasal Route forNaloxone Administration

The intranasal route for naloxone has become more popular recently. This route has several benefits when compared to IV, IM and ET routes. Research studies have demonstrated that intranasal naloxone is equivalent to intravenous naloxone in its effect. This is important for patients with fragile veins and for chronic IV drug abusers with poor veins. Starting an IV may be difficult or impossible in these patients and the intranasal route for drug administration may be their best option to receive medication emergently.11Intranasal atomizers facilitate immediate administration of naloxoneReduction in the risk of needle stick injury and associated potential infectious disease exposureBenefits of Intranasal Route forNaloxone Administration

Although medications can be delivered via the intranasal route with a simple syringe, but mucosal atomization devices (or MADs) provide a focused, directed delivery and dispersal of the medication into the nasal cavity. The use of MADs reduces the risk of needle stick injuries and potential infectious disease exposure.

12On October 16, 2013, the Emergency Medical, Fire, and Transportation Services (EMFTS) Board approved expansion of the Ohio EMS scope of practice to allow emergency medical responders (EMRs) and emergency medical technicians (EMTs) to administer intranasal naloxone to persons suspected of suffering from an opioid overdose upon completion of training and with the approval of the medical directorOhio EMS Scope of Practice

: On October 16, 2013, the Emergency Medical, Fire, and Transportation Services Board approved expansion of the Ohio EMS scope of practice to allow emergency medical responders and emergency medical technicians, upon completion of training and with the approval of the medical director, to administer intranasal naloxone to persons suspected of suffering from an opioid overdose.13Medical director approval is mandatoryA protocol from the medical director is mandatoryTraining is mandatory

Key Points for Intranasal Naloxone Administration

As with all patient care delivered by EMS providers, approval from the medical director is required for the EMS provider to be authorized to administer intranasal naloxone. In addition, a protocol must be provided by the medical director. Training that is approved by the medical director is also required.14The medical director retains the authority to limit or prohibit the administration of intranasal naloxoneThe administration of naloxone by the endotracheal, intramuscular, or intravenous routes remains prohibited for EMRs and EMTs Key Points for Intranasal Naloxone Administration

The Emergency Medical, Fire, and Transportation Services Board determines the Ohio EMS Scope of Practice, and no one, including the medical director, is permitted to exceed this scope. However, the medical director has the authority to limit or prohibit parts of the Ohio EMS Scope of Practice, including the administration of intranasal naloxone. Although EMS providers that are certified as advanced EMTs and paramedics may use a number of routes to give naloxone, emergency medical responders and emergency medical technicians are strictly limited to the intranasal route only.15The dose of naloxone to be administered is determined by the medical directorNaloxone, in the form of a liquid solution, can be drawn up in a syringe or provided as a pre-filled syringeIntranasal Administration Technique

Naloxone is provided as a liquid. It can be drawn into a syringe from a vial or it can come in a pre-filled syringe. The dose of naloxone to be given to a patient is determined by the medical director and should be written in the protocol provided to the EMS provider.16The tip of the syringe should be placed near or just inside the nostrilPlacement of the syringe too far inside the nasal cavity may traumatize the nasal passages or cause epistaxis

Intranasal Administration Technique

During the delivery of naloxone by the intranasal route, the tip of the syringe should be placed near or just inside the patients nostril. If the syringe is placed too far inside the nostril, the nasal passages may be traumatized by the syringe, cause nosebleeds or other damage.17Remove the needle from the syringe prior to administration to prevent trauma to the nasal passages or puncture of the nasal tissues or sinusesThe use of a mucosal atomization device (MAD) on the tip of the syringe prevents nasal trauma and maximizes the delivery of medication to the patientIntranasal Administration Technique

All needles should be removed from the syringe prior to placement of the syringe into the patients nostril. Needles can puncture the patients nasal tissues or sinuses and cause other damage to the patients nasal cavity. A mucosal atomization device is a soft and flexible attachment that is fitted on or can be attached around the tip of a syringe. This device maximizes the delivery of the naloxone to the patient. 18

Mucosal Atomization Device (MAD)This picture shows a mucosal atomization device attached around the end of a syringe. Some syringes, like this one, are designed with a softer plastic tip to draw medication from a vial. The manufacturer may package the syringe and the MAD as one unit as shown in this photograph. The soft plastic tip extends slightly beyond the edge of the MAD. This flexible tip of the syringe is too short to cause significant trauma to the inside of the nasal passages. A MAD can also be applied to the end of a needleless syringe.19Intranasal Medication Delivery

Once the medication is drawn up into the syringe or a pre-filled syringe of the medication is available, the EMS provider should don gloves and any other appropriate personal protective equipment before giving the medication to the patient. The patients head may require manual stabilization by the EMS provider or another member of the EMS team. The narrow end of the mucosal atomization device is placed gently into the patients nostril, and the naloxone is injected into the patients nasal cavity.20Precautions with NaloxoneThe administration of naloxone may result in the rapid onset of the signs and symptoms of opioid withdrawal

AgitationTachycardiaPulmonary edemaNauseaVomitingSeizures

The administration of naloxone may result in the rapid onset of the signs and symptoms of opioid withdrawal. The most frequent signs and symptoms of withdrawal include agitation and combative behavior, tachycardia, pulmonary edema, nausea and vomiting, or seizures.21Prior to the administration of naloxone by all EMS providers, all patients should initially receive the appropriate medical interventions to provide support of their airway, breathing, and circulation (ABCs) Safety Considerations

During the assessment of all patients, including those who are suffering from a suspected opioid overdose, airway, breathing, and circulation remain the top priorities. The airway must be secured and maintained with oxygen provided as necessary. Inadequate respirations should be supported with oxygen delivered via bag valve mask before naloxone is administered. If the patient is pulseless, high quality CPR should be initiated prior to the administration of naloxone.22All patients should be assessed for other causes of altered mental status and/or respiratory depression (hypoxia, hypoglycemia, head injury, shock, stroke) The adverse effects following naloxone administration, particularly in chronic opioid users and abusers, may place the patient and bystanders at riskSafety Considerations

All patients should be assessed for other causes of altered mental status or respiratory depression that include, but are not limited to hypoxia, hypoglycemia, head injury, shock, and stroke. The adverse effects following naloxone administration, particularly in chronic opioid users and abusers, may place the patient, EMS providers and bystanders at risk of physical injury. Prior to the administration of naloxone, EMS providers should consider moving sharp or heavy objects out of the patients reach, or the application of physical restraints in anticipation of combative behavior. Ensure that bystanders are kept at a safe distance. 23Due to the potential adverse effects of naloxone administration, medical professionals often elect to reserve the administration of naloxone to patients with known or suspected opioid overdoses for -Impending cardiopulmonary arrest -Respiratory depression -Shock

Safety Considerations

Due to the risk of uncontrollable agitated behavior, pulmonary edema, and seizures, many healthcare professionals will elect to reserve the administration of naloxone to those patients with respiratory depression, impending cardiopulmonary arrest, or shock.24Safety ConsiderationsThe medical director should include parameters within the protocols for EMRs and EMTs on how to address these adverse effects AgitationTachycardiaPulmonary edemaNauseaVomitingSeizures

When the administration of intranasal naloxone has been approved, the EMS medical director should also provide protocols to emergency medical responders and emergency medical technicians to address the management of the signs and symptoms of opioid withdrawal.25The half-life of naloxone is relatively brief (as short as 30 minutes)All patients who receive naloxone must be monitored closely for recurrent symptoms, including altered mental status, respiratory depression, and circulatory compromiseSafety Considerations

Once naloxone has been administered, it is vital to continue to monitor the patient. The half-life of naloxone is brief and can be as short as 30 minutes. As the effect of the naloxone fades, the signs and symptoms of an opioid overdose can return. Recurrent altered mental status, respiratory depression, or circulatory compromise can follow quickly; therefore, constant patient monitoring and frequent reassessment is essential.26You respond to a known drug abuser who is found unconscious with a hypodermic needle inserted into her arm. Her pupils are pinpoint and she does not respond to painful stimuli. Upon assessment of vital signs, her blood pressure is 110/70, pulse is 60, respiratory rate is 2, and a pulse oximeter reading of 84%.What is the first action you should take?

Practice Case #1

Before you take the test for this education and training module, we would like to provide you the chance to think about the management of two patients who are suspected opioid overdoses.

You respond to a known drug abuser who is found unconscious with a hypodermic needle inserted into her arm. Her pupils are pinpoint and she does not respond to painful stimuli. Upon assessment of vital signs, her blood pressure is 110/70, pulse is 60, respiratory rate is 2, and a pulse oximeter reading is 84%. What is the first action you should take?

27This patient is apneic as evidenced by her respiratory rate of 2. The appropriate initial action to take is to open and maintain the airway and administer oxygen via bag valve mask.Therapeutic interventions to support the patients airway, breathing, and circulation should be initiated prior to the administration of naloxone.Practice Case #1

With a respiratory rate of 2, this patient is apneic. The appropriate initial action is to open and maintain the airway and administer oxygen via bag valve mask. Always remember that airway, breathing, and circulation are the top priority with every patient. In this case, treatment to support the patients airway, breathing, and circulation should be initiated prior to the administration of naloxone28You respond to the home of a diabetic hospice patient with cancer. He has decreased mental status and pinpoint pupils. His wife checked his blood glucose prior to calling 9-1-1 and it is 170. The patient was at his baseline mental status until she applied a transcutaneous fentanyl patch that was recently prescribed for pain control. He has a blood pressure of 130/80, pulse of 70, respiratory rate of 18, and a pulse oximetry reading of 95%.What action should you take?Practice Case #2

This is another patient case for you to manage. You respond to the home of a diabetic hospice patient with cancer. He has decreased mental status and pinpoint pupils. His wife checked his blood glucose prior to calling 9-1-1 and it is 170. The patient was at his baseline mental status until she applied a fentanyl patch that was recently prescribed for pain control. He has a blood pressure of 130/80, pulse of 70, respiratory rate of 18, and a pulse oximetry reading of 95%. What action should you take?29You should follow the protocol that is provided by your medical director.This patient has stable vital signs. Your medical director may direct you to administer intranasal naloxone, remove the fentanyl patch, or transport the patient without any additional medical intervention.The medical director retains the authority to allow, limit, or prohibit the administration of intranasal naloxone by EMS providers.

Practice Case #2

You should follow the protocol that is provided by your medical directorThis patient has stable vital signs. Your medical director may direct you to administer intranasal naloxone, remove the fentanyl patch, or transport the patient without any additional medical intervention other than supportive care and patient reassessment. The medical director retains the authority to allow, limit, or prohibit the administration of intranasal naloxone by EMS providers. Regardless of the training provided by a medical director, an EMS provider can never exceed the Ohio EMS scope of practice for the providers level of EMS certification.30Questions?

ODPS/EMS [email protected] encourage you to direct your questions about this course to the Ohio EMS Instructor overseeing the presentation of this course, to your EMS medical director, or contact the Ohio Department of Public Safety, Division of EMS. Thank you for completing the intranasal naloxone education and training module for Ohio EMS and for your dedicated service to the residents and visitors of Ohio.31Naloxone slide 20Tim ErskineTim Erskine's Album201336231.938eng - iTunNORM 00000467 00000000 000051AF 00000000 000072CB 00000000 00007F85 00007F85 00001FF0 00001FF0eng - iTunSMPB 00000000 00000210 000007E9 0000000000185787 00000000 00000000 00000000 00000000 00000000 00000000 00000000 00000000Naloxone slide 21Tim ErskineTim Erskine's Album201325443.379eng - iTunNORM 00000418 00000000 00007676 00000000 00000449 00000000 00007EE3 00007EE3 000047F0 000047F0eng - iTunSMPB 00000000 00000210 00000A82 000000000011126E 00000000 00000000 00000000 00000000 00000000 00000000 00000000 00000000Naloxone slide 22Tim ErskineTim Erskine's Album201335448.305eng - iTunNORM 0000051B 00000000 00008D53 00000000 00006DCB 00000000 00007F5F 00007F5F 00001C78 00001C78eng - iTunSMPB 00000000 00000210 0000098E 000000000017CEE2 00000000 00000000 00000000 00000000 00000000 00000000 00000000 00000000Naloxone slide 23Tim ErskineTim Erskine's Album201354098.766eng - iTunNORM 00000497 00000000 0000806C 00000000 000045CB 00000000 00007E6C 00007E6C 0000B5A1 0000B5A1eng - iTunSMPB 00000000 00000210 00000733 0000000000245E3D 00000000 00000000 00000000 00000000 00000000 00000000 00000000 00000000Naloxone slide 24Tim ErskineTim Erskine's Album201322413.105eng - iTunNORM 0000074D 00000000 00009057 00000000 0000035E 00000000 00007F02 00007F02 00001E9C 00001E9Ceng - iTunSMPB 00000000 00000210 0000078C 00000000000F0B64 00000000 00000000 00000000 00000000 00000000 00000000 00000000 00000000Naloxone slide 25Tim ErskineTim Erskine's Album201320715.107eng - iTunNORM 000006DE 00000000 00009993 00000000 00002ADB 00000000 00007F4E 00007F4E 00002297 00002297eng - iTunSMPB 00000000 00000210 00000870 00000000000DE600 00000000 00000000 00000000 00000000 00000000 00000000 00000000 00000000Naloxone slide 26Tim ErskineTim Erskine's Album201335657.273eng - iTunNORM 0000040C 00000000 00004511 00000000 00002D1A 00000000 00007F55 00007F55 00002D1A 00002D1Aeng - iTunSMPB 00000000 00000210 0000094F 000000000017F321 00000000 00000000 00000000 00000000 00000000 00000000 00000000 00000000Naloxone slide 27Tim ErskineTim Erskine's Album201341874.094eng - iTunNORM 0000047D 00000000 00008F88 00000000 000015F0 00000000 00007E71 00007E71 000009CB 000009CBeng - iTunSMPB 00000000 00000210 00000799 00000000001C23D7 00000000 00000000 00000000 00000000 00000000 00000000 00000000 00000000Naloxone slide 28Tim ErskineTim Erskine's Album201331556.172eng - iTunNORM 0000084F 00000000 0000E64D 00000000 00000CF5 00000000 00007F6A 00007F6A 00002882 00002882eng - iTunSMPB 00000000 00000210 000009E8 0000000000153008 00000000 00000000 00000000 00000000 00000000 00000000 00000000 00000000Naloxone slide 29Tim ErskineTim Erskine's Album201341012.098eng - iTunNORM 0000067F 00000000 0000ABAC 00000000 00004F63 00000000 00007F22 00007F22 00001778 00001778eng - iTunSMPB 00000000 00000210 00000B17 00000000001B8BD9 00000000 00000000 00000000 00000000 00000000 00000000 00000000 00000000Naloxone slide 30Tim ErskineTim Erskine's Album201345426.562eng - iTunNORM 00000541 00000000 00007CA2 00000000 00004CD6 00000000 00007F5B 00007F5B 00007C97 00007C97eng - iTunSMPB 00000000 00000210 000007B2 00000000001E87BE 00000000 00000000 00000000 00000000 00000000 00000000 00000000 00000000