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]


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


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


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

Characterize the symptoms:
Abdominal cramps
❑ Difficulty in breathing
❑ Dry mouth
Seizure[1] [2]
Examine the patient:
Cyanosis - nails and lips
❑ Decreased bowel sounds
❑ Decreased heart rate
❑ Depressed neurological status
❑ 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]
Respiratory depression (Rate < 12/min)

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 ?
Administer additional naloxone IV 0.5 mg,
Increase in respiratory rate?
Administer additional naloxone IV 2 mg,
Increase in respiratory rate?
Administer additional naloxone IV 4 mg,
Increase in respiratory rate?
Administer additional naloxone IV 10 mg,
Increase in respiratory rate?
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?
Admit to ICU
Observe for 4-6 hours after last naloxone dose
Patient fully awake and alert ?
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


  • If intravenous access cannot be established, naloxone 2 mg, may be administered either intramuscularly (IM) or intra-nasal.
  • Perform baseline studies such as complete blood count (CBC), comprehensive metabolic panel, creatine kinase level, arterial blood gas, chest X Ray to look out for pulmonary edema and abdominal X Ray if body stuffing/packaging is suspected but only after reversal of respiratory depression and when patient has been stabilized.
  • Look out for following complications and treat them:
  • Pulmonary edema: Consider and evaluate if hypoxemia persists despite restoration of respiratory rate. Pulmonary sounds suggesting the same, become more audible after reversal of respiratory depression with naloxone.
  • Rhabdomyolysis: If creatine kinase levels > 5 times the baseline values, diagnose and treat with adequate fluid resuscitation.
  • Myoglobinuric renal failure: Manage with adequate fluid resuscitation.
  • Compartment syndrome: Palpate muscle groups, to look for firmness, swelling and tenderness to diagnose compartment syndrome early.
  • Measure serum acetaminophen levels to account for possible overdose from acetaminophen-opioid combinations. Consult surgery if suspected or confirmed.
  • Treat children with higher doses as needed and observe for atleast 24 hours.
  • Once the patient has been stabilized, completely undress the patient to look for fentanyl patches.
  • Give either pharmacological or mechanical support to respiration in those with respiratory rate less than 12/min.
  • If there is recurrent respiratory depression, then administer naloxone infusion or mechanical intubation and ventilator support, performed in an ICU setting.[6]
  • Consider gastric decontamination with activated charcoal if the patient presents within 1 hour of overdose.[7]



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  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)
  6. Goldfrank, L.; Weisman, RS.; Errick, JK.; Lo, MW. (1986). "A dosing nomogram for continuous infusion intravenous naloxone". Ann Emerg Med. 15 (5): 566–70. PMID 3963538. Unknown parameter |month= ignored (help)
  7. Chyka, PA.; Seger, D.; Krenzelok, EP.; Vale, JA. (2005). "Position paper: Single-dose activated charcoal". Clin Toxicol (Phila). 43 (2): 61–87. PMID 15822758.
  8. Clark, RF.; Wei, EM.; Anderson, PO. "Meperidine: therapeutic use and toxicity". J Emerg Med. 13 (6): 797–802. PMID 8747629.
  9. Zacny, JP. (2005). "Profiling the subjective, psychomotor, and physiological effects of tramadol in recreational drug users". Drug Alcohol Depend. 80 (2): 273–8. doi:10.1016/j.drugalcdep.2005.05.007. PMID 16005162. Unknown parameter |month= ignored (help)