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Ordering Narcan Nasal Spray into Canada (June 3, 2016) and developing a fridge magnet together with Methadone Medical Alert tag would be evidence of Clinical LEADERSHIP.

Position Statement. Opioid DETOXIFICATION is a DEADLY practice as the dead people are finding out through first-hand experience. Click to view PDF

 

Signs and Symptoms Of Methadone/Opiate OVERDOSE

  • Pinpoint pupils
  • Nausea & vomiting yellow bile
  • Dizziness
  • Feeling Intoxicated
  • Sedation/nodding off
  • Unsteady gait/ slurred speech
  • Loud snoring, grunting, groaning,
  • Clenched teeth
  • Hypotension (low blood pressure)
  • Slow pulse (bradycardia)
  • Shallow breathing (hypoventilation)
  • Frothing at the mouth
  • Coma/loss of consciousness
Clinical Practice
Methadone Medical Alert

 

Treatment

  • Activate 9-1-1
  • Give Narcan Nasal Spray
  • CPR – rescue breathing, chest compressions, attach automated external defibrillator (AED) or external pacemaker

*Do not taser – see Mathew Hines video-taped death

www.qtdrugs.org

*Made in Canada, eh! Let it Snow!*

www.crystalcleartransitionalcare.com

#Nasalspray

** see Narcan Nasal Spray Teaching video

https://vimeo.com/269917572/be3c2aa243

Leadership:

  • Development of an extubation checklist using new evidence
Clinical Practice Clinical Practice

Revised 08/19

Extubation Checklist

Patient’s Age:    Gender:  M  / F

Patient’s  Weight =

Indicate

Value/Comment

Reason for Intubation: Circle

Trauma/COPD/Asthma/Head Injury/Opiate overdose (other)

 

 

 

High Risk Extubation?

 

Neck Surgery

Yes

 

No

If yes, consider removal in O.R.

Pre-extubation tests

Airleak test

Chest x-ray (Opiate?, A, B, C, D…)

CT Scan

MRI

Echocardiogram/ECG

Other – state (3T MRI, etc.)

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

Pass/Fail

Patient Assessment

Awake

Follows commands

Agitated

Cooperative

Muscle relaxant reversed

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

 

Medication Review

Analgesia (i.e. opiates - Fentanyl, morphine, tramadol, methadone, etc.)

Benzodiazepines

Lasix (Consider K+ replacement, drug interactions)

IV medications

Antibiotics (Consider for lengthened QTc                           interval)

Yes

Yes

Yes

Yes

 

Yes

No

No

No

No

 

No

Naloxone (Narcan®)

-       NASAL SPRAY

-       intramuscular

-       intravenous

-       subcutaneous

-       endotracheal

-       intranasal

-       sublingual

Lab Review

K+ (WNL)

Hbg (WNL)

Urea (WNL)

Creatinine (WNL)

LKC’s (WNL)

PT/PTT/aPPT

Blood gas interpretation

Other (cultures pending)

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

 

Current value/date

Respiratory Rate

< 20 bpm

Yes

No

 

Temperature

36.1 – 37.2 °C

Yes

No

If febrile, consider sepsis or other

Heart Rate

WNL (<100 bpm)

Yes

No

If tachycardia, correct/consult

Blood Pressure

WNL (Canadian guidelines)

Yes

No

Value/Comment

Pain Scale Pain quality/location

0     1  2  3  4  5  6  7  8  9  10

 

Clinical Practice

Clinical Practice

 

Urine Output

0.5 ml/kg/hr

Yes

No

 

ECG

Normal sinus rhythm

Arrhythmias within last 24 hours

Ectopic beats

QTc interval examined

Yes

Yes

Yes

Yes

No

No

No

No

 

 

If yes, consider cardiac consult

>500 ms 4-fold increase in sudden death

ETCO2

<21

Yes

No

 

SPO2

>90% on 30% FiO2

Yes

No

 

Fluid balance (consider perfusion notes if applicable)

Positive (liters)

Negative

Yes

Yes

No

No

 

Hemodynamically Stable:

 

 

CVP (2 mmHg  – 12 mmHg)

PA Pressure (8-13 mmHg)

Cardiac Output (4-8 L/min)

Intra-arterial pressure (readings are at least 10mmHg higher than cuff BP readings)

Yes

Yes

Yes

Yes

No

No

No

No

 

Sputum Production

Color

Amount (sm, med, lg, copious)

Yes

Yes

No

No

 

Chest Tube

Indications for Removal

(NEJM YouTube Video)

Yes

No

CXR 12-24 hours post removal

Stage of Weaning

Stage 1

 

 

Yes

Yes

Yes

Yes

Yes

Yes

Yes

 

No

No

No

No

No

No

No

Comments

Stage 2 (think about extubation)

date

Stage 3

 

Stage 4

 

Stage 5

 

Stage 6

 

Stage 7

 

Weaning Technique

T-tube trial

PS

Intermittent Mandatory Ventilation (IMV)

Combination of above

Yes

Yes

 

Yes

Yes              

No

No

 

No

No

 

Minute Ventilation – normal is about 6L/min = Ve

<10 L/min

Yes         

No

 

Rapid Shallow Breathing Index (RSBI) = f/Vt ratio

<105

Yes                     

No

 

VC

10-15 mls/kg IBW

Yes

No

 

NIF

-20 to -30 cmH20 minimum acceptable in adult population

Yes          

No

 

Respiratory Rate

20 – 25 bpm

Yes

No

 

Other

Caloric balance restored

Yes

No

 

Consults initiated (state)

See additional sheet 

Yes

No

 

ICD-10 classification

 

Discharge Teaching

Drug-drug interactions (www.qtdrugs.org); CPR/First Aid; Signs & Symptoms of Opiate/Methadone overdose fridge magnet; Signs & Symptoms of Anaphylaxis fridge magnet; medical alert tag; Narcan Nasal Spray teaching video; Narcan Nasal Spray device

 

Organ retrieval: criteria met: yes or no Peer Death Review: Yes/No Chart referred to DNP Yes or No

 

Clinical Practice
Consults

Date Consult Initiated

 

Department

Physician/NP

Allied Healthcare Professional

 

Reason for Consult

 

Follow-up

 

Outcome

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

Cavallone, L. F., & Vannucci, A. (2013). Extubation of the Difficult Airway and Extubation Failure. Anesthesia & Analgesia, 116(2), 368-383.

Howie, W. O., & Dutton, R. P. (2012). Implementation of an evidence-based extubation checklist to reduce extubation failure in patient with trauma: A pilot study. AANA Journal, 80(3), 179-184.

Naloxone: Drug information. (1978-2014). Retrieved from http://www.uptodate.com/contents/naloxone-drug-information?source=search_result&search=narcan&selectedTitle=1%7E98

Ontario Hospital Association. (2011). Strategies for reducing preventable mortality.

The Joint Commission. (2012). Safe use of opioids in hospitals. Retrieved from http://www.jointcommission.org/assets/1/18/SEA_49_opioids_8_2_12_final.pdf

Tobin, M. J. (2006). Principles & practice of mechanical ventilation (2nd ed.). New York: McGraw-Hill.

Urden, L. D., Stacy, K. M., & Lough, M. E. (2002). Thelan’s critical care nursing diagnosis and management (4th ed.). St. Louis, Missoursi: Mosby Inc.

Van Noorde, C., Eijgelsheim, M., & Stricker, B. H. (2010). Drug- and non-drug-associated QT interval prolongation. British Journal of Clinical Pharmacology, 70(1), 16-23.