Narcan Overdose. Too Much of a Good Thing?

    NextPrevious

    Narcan Overdose. Too Much of a Good Thing?

    What do smack, dragon, horse, salt, brown sugar, china white, and black pearl have in common? That’s right… they are all nicknames for heroin. We all know that Naloxone (Narcan) is a useful antidote in overdose, however appropriate dosing and timing can be more of an art than a science.

     

    The most important concept to remember is that you are looking to treat respiratory depression, not restore a normal level of consciousness. You can always give more if needed, but putting a patient into acute withdrawal will do you (and your patient) more harm than good.

     

    Many physicians start with 0.4mg IV, but this can be too large of a dose for many patients. If the patient has spontaneous respirations, try taking that 0.4mg dose and diluting it with 9cc of normal saline. You now have a 10mL syringe with 0.4mg of Narcan, which is 0.04mg/mL. You can give 1mL aliquots until the respiratory rate improves to greater than 12.

     

    For large overdoses or longer acting opioids, repeated dosing may be necessary. For those of us who don’t have time to run to the bedside every 30 mins, a narcan drip may be useful. If you take 2/3 of the bolus dose needed to reverse respiratory depression and infuse this every hour you will maintain plasma naloxone levels (Goldfrank et al. 1986).

     

    TL;DR

    Titrate Narcan to RR >12, not normal mental status

    Narcan Bolus: 0.4mg naloxone + 9cc normal saline = 10cc of 0.04mg/cc naloxone (give 1cc aliquots)

    Narcan Drip: (mg of naloxone needed to reverse respiratory depression) x (2/3) = (mg per hour)

     

    Sources:

    Goldfrank L, et al. A dosing nomogram for continuous infusion intravenous naloxone. Ann Emerg Med. 1986 May;15(5):566-70.

    Stolbach, A and Hoffman, RS. Acute opioid intoxication in adults. In UpToDate, Traub, SJ (Ed) UpToDate, Waltham, MA, 2018

    Blue Magic. Digital Image. We Are The Mighty. 2019, https://www.wearethemighty.com/news/how-drug-dealers-used-the-us-military-to-smuggle-heroin

    • Welcome! This is the website for the Mount Sinai Emergency Ultrasound Division. It serves as an information resource for residents, fellows, medical students and others seeking information about point-of-care ultrasound. There is a lot ofRead more

    • Lewis Leads & Invisible P’s

      You ever have a tough time visualizing P waves on EKGs? Have no fear, a Lewis Lead EKG might just be the thing you need! The Lewis Lead (aka S5) is a modified EKG obtained in a mannerRead more

    • Head Scratcher of a Head CT?

      Hey there guys and gals and welcome back to my channel! If you’re like me and TERRIBLE at reading your own imaging studies, settle in for a quick 20 minute run down for all thoseRead more

    • Central Line Troubleshooting. Beyond the Basics.

      Needle, wire, nick, dilate, catheter. Sounds simple right? However, simple doesn’t always mean easy. Placing a central line on a mannequin can be much easier than the 250lb ESRD patient with peripheral vascular disease andRead more

    • Health Information Exchange: Quest for the Omni-Chart.

      Have you ever opened a chart of a very sick or obtunded patient, only to find it completely blank? Of course you have…probably at some point today. The minor panic that having to find vitalRead more

    • Clinical Decision Support…your daily helper.

      Continuing with the theme of clinical informatics, today we will touch on the topic of Clinical Decision Support Systems (CDSS), or sometimes just called Clinical Decision Support (CDS). The basic premise of clinical decision supportRead more

    • What Is Clinical Informatics?

      If you loved the super sexy topic of cerumen impaction yesterday…Well, hold on to your socks, because today we will continue our rousing educational foray by tackling the riveting question: What is Clinical Informatics? ShallRead more

    • Cerumen Impaction: an Update.

      The last time www.sinaiem.org addressed the topic of cerumen (ear wax) impaction was in 2013. See this post: http://sinaiem.org/50yo-man-with-chest-pain-and-also-with-r-ear-pain/  If you’re like me, you likely believe that the world of cerumen impaction is a rather staticRead more

    • Cervical Artery Dissection

      Cervical artery dissection (CAD) accounts for 1-2% of all ischemic strokes but 10-25% of strokes in younger individuals.  CAD includes extracranial carotid and vertebral artery dissections.  A review of the literature suggests that there mayRead more

    NextPrevious