Opioid overdose resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Vidit Bhargava, M.B.B.S [2]

Definition

Opioid overdose is defined as an acute condition due to excessive use of opioids/narcotics.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Opioid overdose is by itself life threatening and should be treated as such irrespective of the causes.

Common Causes

Management

Shown below is an algorithm summarizing the diagnostic approach to Opioid overdose:

 
 
 
 
 
 
 
Characterize the symptoms:
Abdominal cramps
Constipation
❑ Difficulty in breathing
Drowsiness
❑ Dry mouth
Seizure[1] [2]
Stupor
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:
Bradypnea/apnea
Cyanosis - nails and lips
❑ Decreased bowel sounds
❑ Decreased heart rate
❑ Depressed neurological status
Hypothermia
Miosis
❑ Presence of one or more fentanyl patches
❑ Shallow and deep respiration
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider alternative diagnosis:
Gammahydroxybutyrate/gammabutyrolactone overdose
Alcohol intoxication
Sedative hypnotics
Phencyclidine (PCP) overdose
Ketamine overdose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic triad: (not present in all the cases)[3]
Miosis
Respiratory depression (Rate < 12/min)
Stupor
 
 
 
 



Initial Management

Shown below is an alogorithm summarizing the basic approach to naloxone (Narcan) administration:[4][5]


 
 
 
 
 
 
 
Administer naloxone IV 0.04 mg in adults and
0.1 mg/kg in pediatric patients stat,
Increase in respiratory rate ?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
Observe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer additional naloxone IV 0.5 mg,
Increase in respiratory rate?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
Observe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer additional naloxone IV 2 mg,
Increase in respiratory rate?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
Observe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer additional naloxone IV 4 mg,
Increase in respiratory rate?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
Observe
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Administer additional naloxone IV 10 mg,
Increase in respiratory rate?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
Further management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Consider other diagnostic possibilities
 
 
 
 



Futher Management

Shown below is an algorithm summarizing the comprehensive approach to ICU management of patients with opioid overdose:[5]

 
 
 
 
 
Opioid overdose: Respiratory rate < 12/min
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Oxygenate with bag and mask, administer naloxone with a gradually increasing dose till reversal of respiratory depression is seen
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History of use of morphine, fentanyl or other long acting opioids?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Yes
 
 
 
No
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Admit to ICU
 
 
 
Observe for 4-6 hours after last naloxone dose
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient fully awake and alert ?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform intubation, begin a continuous naloxone infusion
 
Admit to ICU
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Continue infusion till respiratory depression reversed, observe 4-6 hours after naloxone infusion is stopped
 
 
 
 
 
Discharge patient, when awake & alert with stable vital signs
 
 
 
 
 
 

Do's

Dont's

References

  1. Talaie, H.; Panahandeh, R.; Fayaznouri, M.; Asadi, Z.; Abdollahi, M. (2009). "Dose-independent occurrence of seizure with tramadol". J Med Toxicol. 5 (2): 63–7. PMID 19415589. Unknown parameter |month= ignored (help)
  2. Kaiko, RF.; Foley, KM.; Grabinski, PY.; Heidrich, G.; Rogers, AG.; Inturrisi, CE.; Reidenberg, MM. (1983). "Central nervous system excitatory effects of meperidine in cancer patients". Ann Neurol. 13 (2): 180–5. doi:10.1002/ana.410130213. PMID 6187275. Unknown parameter |month= ignored (help)
  3. Hoffman, JR.; Schriger, DL.; Luo, JS. (1991). "The empiric use of naloxone in patients with altered mental status: a reappraisal". Ann Emerg Med. 20 (3): 246–52. PMID 1996818. Unknown parameter |month= ignored (help)
  4. "American Academy of Pediatrics Committee on Drugs: Emergency drug doses for infants and children". Pediatrics. 81 (3): 462–5. 1988. PMID 3422026. Unknown parameter |month= ignored (help)
  5. 5.0 5.1 Boyer, EW. (2012). "Management of opioid analgesic overdose". N Engl J Med. 367 (2): 146–55. doi:10.1056/NEJMra1202561. PMID 22784117. Unknown parameter |month= ignored (help)