Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Basis of Treatments in EMS – Naloxone Part I

In A firetender seeks reality from Rogue! firetender writes –

Aloha, Rogue, it’s your friendly firetender here!
You know how I’ve been getting carried away by my insistence that almost everything I used as a medic back in 1980 has been debunked if not banned? Well, it really may have gotten out of hand.

and –

would you please let me know whether each is, IN or OUT; PROVEN or DISPROVEN; PRAISED or CONDEMNED or whatever quick comment might be helpful for me to get a handle on just how useful was the stuff I used back then. What has lasted? What is suspect?

OK. I will see if I can cover one of these a week.

I’ll start with a common one and one that I have written a bunch about – naloxone (Narcan).

I don’t know if EMS originally used the initial dose of 0.4 mg or 2.0 mg. I have seen both doses in systems where I have worked.

I have read somewhere, and I do not remember where, that the dose of 0.4 mg naloxone was the amount that would completely reverse 10 mg morphine in an opioid-naive patient (someone who had not developed a tolerance to opioids). I wouldn’t know from experience. I have never had to reverse any dose of any opioid I have given. If I did, it is extremely unlikely that I would want to completely reverse the effects.

My dosing (for any pre-existing overdose suspected of being due to opioids) is 0.02 mg to 0.04 mg naloxone until respirations improve. Suspicion of opioid overdose would be due to pin point pupils, respiratory depression, decreased level of consciousness, and some good reason to believe that opioids were taken.

We no longer should be routinely giving this, or any other, part of the Coma Cocktail just because we do not trust medics to diagnose.

I wonder what paralysis of intellect gave birth to this idea. This is equivalent to going duck hunting and shooting three or four shotgun rounds at a flock of birds hoping you’ll hit the single mallard flying in the middle. EMS is more sophisticated than this.[1]

Naloxone is a drug and should be given for specific indications. Naloxone should not be given as part of a shotgun approach that is designed to accommodate incompetent medics.

naloxone should be used only when the patient exhibits signs or symptoms of narcotic overdose or when something found in the environment points to the possibility of narcotic overdose.

If and when naloxone is indicated, administer it only in low, titrated doses to carefully reverse the respiratory depression.[1]

Is naloxone diagnostic?

The heroin overdose syndrome (sensitivity for diagnosing heroin overdose, 92%; specificity, 76%) consists of abnormal mental status, substantially decreased respiration, and miotic pupils. The response of naloxone does not improve the sensitivity of this diagnosis.[2]

and –

Six of the 25 complete responders to naloxone (24%) ultimately were proven to have had false-positive responses, as they were not ultimately given a diagnosis of opiate overdose. In four of these patients, the acute episode of AMS was related to a seizure, whereas in two, it was due to head trauma; in none of these cases did the ultimate diagnosis include opiates or any other class of drug overdose (which might have responded directly to naloxone). Thus, what was apparently misinterpreted as a response to naloxone in these cases appears in retrospect to have been due to the natural lightening that occurs with time during the postictal period or after head trauma.[3]

If there is a shortage of people to stimulate breathing, or to ventilate the patient, then naloxone can be very useful.

Naloxone can reverse the effects of opioid overdose, but naloxone is too often used as a crutch for bad skills.


[1] No more coma cocktails. Using science to dispel myths & improve patient care.
Bledsoe BE.
JEMS. 2002 Nov;27(11):54-60.
PMID: 12483195 [PubMed – indexed for MEDLINE]

Page with link to Free Full Text PDF download from Dr. Bledsoe’s website

[2] Acute heroin overdose.
Sporer KA.
Ann Intern Med. 1999 Apr 6;130(7):584-90. Review.
PMID: 10189329 [PubMed – indexed for MEDLINE]

[3] The empiric use of naloxone in patients with altered mental status: a reappraisal.
Hoffman JR, Schriger DL, Luo JS.
Ann Emerg Med. 1991 Mar;20(3):246-52.
PMID: 1996818 [PubMed – indexed for MEDLINE]



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