Recently retired EMT here. I never found the nasal spray to be very effective for a number of reasons. The patient has to be breathing, absorption rate is highly variable and it is difficult to adjust the dose. In fact, our protocols did not allow the dose to be adjusted with the intranasal route.

IV push is the best, though SQ and IM are pretty good. IM and SQ are slow acting. You have to slowly bring the patient up. The important thing is to titrate dosage to rate and depth of breathing and slowly bring the patient up. If you push a large dose and suddenly rip the patient out of their warm, fuzzy cloud, into a world of hurt, they will often come up swinging.

You can breathe for a patient with artificial respiration for as long as needed, there is no rush to slam the Narcan in quickly. In fact, the protocols I ran under said nothing about bringing an OD patient back to consciousness, only to ensure adequate air exchange.

Also, talk to the patient with soothing, caring tones. Even though they are not responding, they can still hear you, increasingly so as the Narcan takes effect.

I never had a patient swing at me after administering Narcan once learning technique from a master that had administered literally gallons of the stuff over his career.

Some of the more jaded EMTs will purposely slam an OD patient with Narcan to punish them for using. This is just wrong.