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Podcast 912: Narcan (Naloxone)

Emergency Medical Minute

Release Date: 07/15/2024

Episode 984: Fish Hooks show art Episode 984: Fish Hooks

Emergency Medical Minute

Contributor: Megan Hurley, MD Educational Pearls: Assess first: confirm the hook isn’t near vital structures. Automatic subspecialty consult for eye involvement or proximity to carotid artery, radial artery, peritoneum, testicle, or urethra Barbed hook: cannot be pulled back through the entry without disengaging the barb Removal Techniques String-Pull: best for superficial, single-barbed hooks Depress shank and eye of hook to disengage barb and then pull string taut and jerk suddenly along the long axis Can only be used when the hook is in a body part that can be firmly secured so it...

info_outline Episode 983: Head-of-Bed Position in Large Vessel Occlusion Strokes show art Episode 983: Head-of-Bed Position in Large Vessel Occlusion Strokes

Emergency Medical Minute

Contributor: Aaron Lessen MD Educational Pearls:  Recent prospective randomized clinical trial assessed optimal head-of-bed positioning in patients with LVO 0º vs. 30º elevation Objective was to determine superiority of the two angles in stability prior to thrombectomy for LVO patients 45 patients randomized to the group with 0° head positioning and 47 patients randomized to the group with 30° head positioning Patients in the 30º group experienced worsening of NIHSS by 2 points or more Patients with head position at 0° showed score stability Hazard ratio 34.40; 95% CI,...

info_outline Episode 982: Epistaxis Management show art Episode 982: Epistaxis Management

Emergency Medical Minute

Contributor: Meghan Hurley, MD Educational Pearls: 1. Initial Assessment Start with a physical examination: Determine if the bleed is anterior or posterior. Perform a primary survey: assess airway, breathing, and circulation (ABCs). Airway compromise = intubation immediately. If the patient is stable, have them blow out any clots, then re-examine the nares. 2. Topical Medications Anesthetics: provide local anesthesia and pain relief. Lidocaine Tetracaine Vasoconstrictors: reduce bleeding. LET (Lidocaine, Epinephrine, Tetracaine) is ideal because it provides...

info_outline Episode 981: Electrical Burns show art Episode 981: Electrical Burns

Emergency Medical Minute

Contributor: Travis Barlock, MD Educational Pearls: Quick Statistics on Electrical Burns: Electrical burns compose roughly 2 to 9% of all burns that come into emergency departments. The majority of patients who receive electrical burns are male, typically aged 20’s to 30’s, accounting for 80 to 90% of all electrical burn victims. The majority of burns are linked to occupational exposure. The upper extremities are more commonly impacted by electrical burns, accounting for 70 to 90% of entry points into the body during an exposure. What are some of the key considerations in electrical...

info_outline Tox Talks 2025 Recap 1, Digoxin and Beta Blockers show art Tox Talks 2025 Recap 1, Digoxin and Beta Blockers

Emergency Medical Minute

Contributors: Preeya Prakash MD, Adam Greenhaw PharmD, Travis Barlock MD, and Jeffrey Olson MS4 In this episode, cardiologist Preeya Prakash and medical student Jeffrey Olson listen in as two cases are presented from EMM’s recent event, Tox Talk 2025.  Talk 1- Digoxin Overdose Dr. Adam Greenhaw presents a case of a Digoxin overdose along with many pearls. During the studio listen in, Dr. Prakash helps to answer the questions of: How does digoxin work? Why might a patient still be on digoxin in 2025? What are the EKG findings of digoxin toxicity? Is there any utility in atropine...

info_outline Episode 980: Brain Injury Guidelines (BIG) show art Episode 980: Brain Injury Guidelines (BIG)

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: Traumatic Brain Injuries are a frequent complaint in the Emergency Department and have increased in recent years. The American Association for Surgery of Trauma (AAST) has created Brain Injury Guidelines (BIG), in an attempt to categorize brain injuries and the level of treatment they require. They are… BIG 1 Normal neuro exam Not intoxicated Not on anticoagulation or antiplatelet medications Minimal findings on head CT No fracture <4 mm bleed (subdural, epidural, intraparenchymal (max one location)) Maximum of “trace” subarachnoid...

info_outline Episode 979: Oral vs Temporal Thermometers show art Episode 979: Oral vs Temporal Thermometers

Emergency Medical Minute

Contributor: Taylor Lynch, MD Educational Pearls: A recent study published in a pediatric journal in April 2025 compared temporal and oral thermometers Paired temperature measurements (temporal and oral temperature within 30 minutes) were obtained from 1,412 pediatric patients 26% of patients had statistically different temporal and oral temperatures The temporal reading was always lower than the oral reading Children less than 12 years old were 2-3x more likely to actually have that statistical difference in temperatures The study also evaluated 1,000 adult patients 36% had a temporal...

info_outline Episode 978: Delusional Parasitosis show art Episode 978: Delusional Parasitosis

Emergency Medical Minute

Contributor: Taylor Lynch, MD Educational Pearls: Delusional parasitosis is a subtype of the psychiatric condition delusional disorder Defined as a fixed, false belief of infestation by parasites or other organisms A somatic type of delusional disorder Primary delusional parasitosis Occurs in the absence of other psychiatric or medical conditions Secondary delusional parasitosis Causes include methamphetamine use disorder, schizophrenia, neurologic diseases, or medical conditions such as thyroid disease Pathophysiology Poorly understood Upregulation of striatal dopamine system is...

info_outline Episode 977: Amyloid Therapy and Stroke-like Events show art Episode 977: Amyloid Therapy and Stroke-like Events

Emergency Medical Minute

Contributor: Aaron Lessen, MD Educational Pearls: The cause of Alzheimer’s disease is multifactorial, but the most widely suspected mechanism is the amyloid cascade hypothesis: Beta-amyloid proteins accumulate in the central nervous system, forming plaques that impair neuronal function. In recent years, advances have led to the development of targeted therapies with monoclonal antibodies. These drugs: Work by degrading amyloid plaques Slow the rate of cognitive decline and disease progression Have major side effects, most notably the development of amyloid-related imaging abnormalities...

info_outline Episode 976: Improvised Burr Hole in an Epidural Hematoma show art Episode 976: Improvised Burr Hole in an Epidural Hematoma

Emergency Medical Minute

Contributor: Alec Coston, MD Case Report Summary: A 17-year-old female involved in a motor vehicle collision presented to a rural emergency facility via personally operated vehicle. During workup and initial CT scan, the patient began rapidly decompensating with CT revealing a 1.5cm epidural hematoma with 7mm of midline shift. The patient went from being able to walk and talk to being obtunded with a blown left pupil and unresponsive. Following intubation, the patient was being prepared for transport but potential delays required immediate emergency evacuation of the hematoma via a Burr Hole....

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Contributor: Taylor Lynch, MD

Educational Pearls:

Opioid Epidemic- quick facts

  • Drug overdoses, primarily driven by opioids, have become the leading cause of accidental death in the U.S. for individuals aged 18-45.

  • In 2021, opioids were involved in nearly 75% of all drug overdose deaths

  • The rise of synthetic opioids like fentanyl, which is much more potent than heroin or prescription opioids, has played a major role in the increase in overdose deaths

What is Narcan AKA Naloxone?

  • Competitive opioid antagonist. It sits on the receptor but doesn’t activate it.

When do we give Narcan?

  • Respiratory rate less than 8-10 breaths per minute

Should you check the pupils?

  • An opioid overdose classically presents with pinpoint pupils BUT…

  • Hypercapnia from bradypnea can normalize the pupils

  • Taking other drugs at the same time like cocaine or meth can counteract the pupillary effects

  • Basilar stroke could also cause small pupils, so don’t anchor on an opioid overdose

How does Narcan affect the body?

  • Relatively safe even if the patient is not experiencing an opioid overdose. So when in doubt, give the Narcan.

  • What if the patient is opioid naive and overdosing?

    • Use a large dose given that this patient is unlikely to withdraw

    • 0.4-2 mg every 3-5 minutes

  • What if the patient is a chronic opioid user

    • Use a smaller dose such as 0.04-0.4 mg to avoid precipitated withdrawal

How fast does Narcan work?

  • Given intravenously (IV), onset is 1-2 min

  • Given intranasal (IN), onset is 3-4 min

  • Given intramuscularly (IM), onset is ~6 min

  • Duration of action is 60 mins, with a range of 20-90 minutes

How does that compare to the duration of action of common opioids?

  • Heroine lasts 60 min

  • Fentanyl lasts 30-60 min, depending on route

  • Carfentanyl lasts ~5 hrs

  • Methadone lasts 12-24 hrs

  • So we really need to be conscious about redosing

How do you monitor someone treated with Narcan?

  • Pay close attention to the end-tidal CO2 to ensure that are ventilating appropriately

  • Be cautious with giving O2 as it might mask hypoventilation

  • Watch the respiratory rate

  • Give Narcan as needed

  • Observe for at least 2-4 hours after the last Narcan dose

  • Larger the dose, longer the observation period

Who gets a drip?

  • If they have gotten ~3 doses, time to start the drip

  • Start at 2/3rds last effective wake-up dose

Complications

  • Flash pulm edema

    • 0.2-3.6% complication rate

    • Might be from the catecholamine surge from abrupt wake-up

    • Might also be from large inspiratory effort against a partially closed glottis which creates too much negative pressure

    • Treat with BIPAP if awake and intubation if not awake

Should you give Narcan in cardiac arrest?

  • Short answer no. During ACLS you take over breathing for the patient and that is pretty much the only way that Narcan can help

  • Just focus on high quality CPR

References

Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII