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CE ARTICLE and nasal gastric tubes can improve patient outcomes by placing a gastric tube and administering activated charcoal via the NG/OG tube when patients cannot be trusted to swallow. Involving medical control in a decision this important—and with a procedure that has such signifcant side effects—is always a good idea. really hurt and I wanted some relief." He is transferred to the ambulance and transported to the ED without incident, though he requires an additional 1.2 mg of IV naloxone en route. Scenario Conclusion 2. Centers for Disease Control and Prevention. Vital Signs: Prescription Painkiller Overdoses in the U.S., www.cdc.gov/ vitalsigns/painkilleroverdoses/. The paramedic, Linda, arrives on scene and takes a report from Bob and Jerry. She immediately asks Mrs. Smith, "Are there any pain medications in the house—maybe an old prescription for him or one for you?" "No," Mrs. Smith replies,"but my son takes pain medications. He's had many back surgeries and is out of work on disability. Should I call him?" "Please do," Linda replies. She then administers 2.0 mg of naloxone IN and prepares to place Mr. Smith on the cardiac monitor while Jerry sets up her equipment for an IV attempt. "He's waking up, and his breathing is picking up," Bob says, pulling the BVM off Mr. Smith's face but continuing to give oxygen via blow-by. "Well, that answers that question!" Linda says with a smile. "If this is an opioid overdose, why are his pupils not pinpoint?" Bob asks. "I know some opioid overdoses won't result in pinpoint pupils, but I'm not sure which ones," Linda replies. "My son is coming right over," Mrs. Smith says as she comes back from the kitchen. "He says he gave my husband some of his Demerol because he was in so much pain." Linda initiates IV access with an 18-gauge catheter in Mr. Smith's left arm. Mr. Smith is now conscious and alert to pain. His son arrives, visibly upset, and tells the EMS crew and his mother how he gave his father fve 100-mg tablets of Demerol to use for his back pain. "I told him to be careful with it and not take more than one every six hours," the son laments. "I didn't mean for this to happen!" Mr. Smith's level of consciousness and mental status eventually improve to where he can describe taking all 500 mg of the Demerol "because my back REFERENCES 1. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS), www.cdc.gov/injury/wisqars/index.html. 3. Substance Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, www. samhsa.gov/data/nsduh/2k10nsduh/2k10results.htm. 4. Op cit., Centers for Disease Control and Prevention, Vital Signs. 5. Soto J, Sacristan JA, Alsar MJ. Pulmonary oedema due to fentanyl? Anaesthesia, 1992 Oct; 47: 913–4. 6. Bardsley CH. Chapter 160: Opioids. In: Marx J, Hockberger R, Walls R, Rosen's Emergency Medicine, 7th ed. Mosby, 2010. 7. PulmCCM. Managing Opioid Overdose in the ICU (Review, NEJM), http://pulmccm.org/2012/critical-carereview/managing-opioid-overdose-in-the-icu-review-nejm/. 8. Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, 1999–2006. NCHS Data Brief, 2009 Sept, www. cdc.gov/nchs/data/databriefs/db22.pdf. 9. Doyon S. Chapter 180: Opioids. In: Tintinalli JE, et al., Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 7th ed. New York: McGraw-Hill, 2011. 10. Robertson TM, Hendey GW, Stroh G, Shalit M. Intranasal naloxone is a viable alternative to intravenous naloxone for prehospital narcotic overdose. Prehosp Emerg Care, 2009 Oct–Dec; 13(4): 512–5. 11. Barton ED, et al. Effcacy of intranasal naloxone as a needleless alternative for treatment of opioid overdose in the prehospital setting. J Emerg Med, 2005 Oct; 29(3): 265–71. 12. Morbidity and Mortality Weekly Report. Communitybased opioid overdose prevention programs providing naloxone—United States, 2010. MMWR, 2012 Feb 17; 61(6): 101–5. 13. Olson KR. Activated charcoal for acute poisoning: one toxicologist's journey. J Med Toxicol, 2010; 6: 190–8. Scott R. Snyder, BS, NREMT-P, is a faculty member at the Public Safety Training Center in the Emergency Care Program at Santa Rosa Junior College, CA. E-mail scottrsnyder@me.com. Sean M. Kivlehan, MD, MPH, NREMT-P, is an emergency medicine resident at the University of California, San Francisco. E-mail sean.kivlehan@gmail.com. Kevin T. Collopy, BA, FP-C, CCEMT-P, NREMT-P, WEMT, is performance improvement coordinator for Vitalink/Airlink in Wilmington, NC, and a lead instructor for Wilderness Medical Associates. E-mail kcollopy@colgatealumni.org. SCOTT SNYDER, SEAN KIVLEHAN AND KEVIN COLLOPY are featured speakers at EMS World Expo 2013, Sept. 8–12, Las Vegas Convention Center, Las Vegas, NV. For more information, visit EMSWorldExpo.com tion has been explored with favorable results, and it arguably is a safe and effective treatment that can be utilized in the EMS environment.10,11 In fact, IN naloxone is so easy to administer that nonmedical persons have been trained in its use in community-based opioid overdose prevention programs, with positive outcomes. In the February 17, 2012 issue of Morbidity and Mortality Weekly Report, the CDC reported that more than 53,000 laypersons from at least 15 states had been trained in administration of IN naloxone and reported the successful reversal of over 10,000 episodes of opioid overdose.12 The dose of naloxone is 0.4–2.0 mg for adults and children. Higher doses may be required for synthetic opioids such as fentanyl. Naloxone administration can result in acute withdrawal symptoms in patients who are physically dependent on their drug. Patients with suspected opioid dependency can receive a titrated dose of naloxone starting at 0.4 mg and administered in 0.4-mg increments until respiratory depression is corrected. Naloxone can also be a valuable diagnostic tool, as in the case of a patient with an altered level of consciousness of unknown etiology. In many prehospital protocols, such a patient would receive a dose of naloxone. If the patient responds, it can be concluded that opioids at least contributed to the patient's decreased level of consciousness. Consider administration of activated charcoal in patients who are conscious, alert and oriented, can protect their airway, and have an oral opioid ingestion that occurred within the hour.6,9 Activated charcoal has fallen out of favor for oral overdoses in general, but it has a proven benefit in patients when given soon after drug ingestion. Given orally, the common dose in children and adults is 1.0 g/kg, or adults may receive a limited dose of 50–100 g.6 As the risk of vomiting is high in patients with opioid toxicity, consider carefully the risk of decreasing mental status and level of consciousness, loss of the ability to protect the airway, and the possibility of vomiting or regurgitation and subsequent aspiration. Paramedics who routinely place oral EMSWORLD.com | JUNE 2013 61