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Questtion for WY Dave
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WYDave
Posted 12/3/2022 21:37 (#9963969 - in reply to #9962103)
Subject: RE: Questtion for WY Dave


Wyoming

"Narcan" is the brand name for the drug known by the generic name "naloxone."

I've not had to administer it personally. I've been on a scene where someone else administered it, while I was ready to deal with the overdose patient about to come out of their stupor. One of the results of being one of the larger guys on a EMS scene who has a strong back is that sometimes, you're allocated to do the donkey work of EMS. 

Will it save the life of someone that had an overdose? That depends.

Opioids and opiates (opioids are synthetic opiates, and opiates are naturally occurring substances like heroine, morphine, opium, etc., suppress the breathing reflex. I'll try to explain this as briefly as possible.

Your breathing reflex isn't driven directly by your brain - it is a "reflex," meaning that you don't have to think about it; you can, if you want, and you can both hold your breath or hyperventilate voluntarily by invoking higher parts of your brain. But for everyday, not-thinking-a-second-about-it breathing, your breathing reflex is driven by the CO2 levels in your bloodstream and a small number of neurons in your brain stem - that part of your brain that connects the "big" part of your brain to your spinal cord.

When you are breathing normally, without drugs in your system, (and without a history of chronic hypoxia, as would happen in people with COPD1), your breathing reflex is driven by CO2 levels in your bloodstream. As your CO2 levels rise, your brainstem "fires" and causes a breath to happen.

OK, so now take on too much opioids/opiates, and what happens is that the drugs latch onto the opioid receptors in your brain (for pain) and in the brainstem (where they have effects on the breathing reflex), and the patient starts to exhibit a slow, irregular breathing, and attending rise in blood CO2 levels and a decrease in O2 levels. At some point, this will start to cause brain damage. Now the patient starts downhill in a hurry.

At this point, the patient might still be breathing, but slowly and irregularly. EMS medics have a saying "Breathing under eight, intubate" (and then ventilate or "bag") the patient to make up for the slow breathing that is causing hypoxia (low O2 levels). 

A typical dose of naloxone (Narcam) is 2 mg. Training is to administer a dose, wait for 3 to 5 minutes to observe for effect, then administer another dose. Recent research calls for this to be superseded with a 8mg dose at initial administration. Administering naloxone in excess hasn't shown any bad effects at this time.

With regard to fentanyl: Fentanyl is known to bind to opioid receptors in the nervous system both more rapidly and more tightly than opiates (ie, naturally occurring medications).  This means that an overdose caused by (eg) heroin might require less naloxone to reverse than an overdose of fentanyl. Illicit street drugs aren't known for exact dosages of fentanyl, and there's no telling how much fentanyl a person might have taken on. This means that treating fentanyl OD's may take several 2 mg doses of naloxone. 

The result is that perhaps 20 to 25% of fentanyl overdoses might not be reversed with naloxone - the damage to the brain by high CO2 levels and low O2 levels has already been done. 

1 - people who have COPD eventually have a change in their brain's response for breathing drive - they become less responsive to high CO2 levels and more driven by O2 levels; when their O2 levels drop too low (eg, under 89 to 92% O2 blood saturation), they breath. In EMS, we learn that if you flood these types of patients with O2, they can actually slow down their breathing dramatically - because they're no longer being driven by CO2 levels. The result is that people with COPD eventually are known to have resting oxygen saturations in the low/mid 90's at best. 

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