Nebulized Naloxone

Weber, et al. Prehosp Emerg Care,

2mg naloxone nebulized with 3mL normal saline
105 cases- 22% complete response, 59% partial response, 19% no response
No adverse events, no intubations or BVM ventilations
Only 10% were given a second dose of naloxone
Unclear how response was determined (likely subjective)

Baumann et al. Am J Emerg Med, 2013

Observational study of 26 patients (out of 54) in an urban ED setting
Route of administration based on physician discretion. Opioid intoxication was defined a priori as any patient who arrived in the ED with either a depressed sensorium or respiratory drive and a history of opioid use as provided by either the patient or prehospital
Minimum RR was 6 to be included
Pts received 2mg in 3mL NS.
Median GCS scores improved from 11 to 13, median RASS scores improved from -3.0 to -2.0, and need for supplemental O2 decreased from 81% to 50%.
Eleven of the 26 required a second dose of medication, and three of those eleven went on to require a third dose.
12% reported moderate-to-severe agitation.

TAKE HOME:

Naloxone indicated in presumed/confirmed opiate overdose with RR < 12
1-2mg in 3-5mL NS
Needle-less, steady low-maintenance dose
Self-titrating because when patient awakens, he/she will pull off the mask, but requires a spontaneously breathing patient
Half-life of naloxone approx. 1 hour; opioid half-line depends on agent
Be mindful of causing withdrawal
Can always escalate treatment to IN/IM/SQ/IV formulations
Naloxone drip: hourly infusion rate calculated as 2/3rds of the total bolus dose given to achieve the desired opioid reversal effect

Dr. Youn presents today’s edition of Morning Report!

REFERENCES:

Baumann BM, Patterson RA, Parone DA, et al. Use and efficacy of nebulized naloxone in patients with suspected opioid intoxication. Am J Emerg Med. 2013; 31: 585-588.

Mycyk MB, Szyszko AL, Aks SE. Nebulized naloxone gently and effectively reverses methadone intoxication. J Emerg Med. 2003 Feb;24(2):185-7.

Weber JM, et al. Can nebulized naloxone be used safely and effectively by emergency medical services for suspected opioid overdose? Prehosp Emerg Care. 2012 Apr-Jun;16(2): 289-292.

Academic Life in EM. Trick of the trade: nebulized naloxone. http://academiclifeinem.com/trick-of-the-trade-nebulized-naloxone/ Accessed November 29, 2014.