Opioid overdose resident survival guide
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
- Accidental overdose
- Simultaneous use with other illicit drugs, sedative hypnotics
- Rupture of package inside body cavity in body packers, body stuffers
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 ❑ Stupor | |||||||||||||||||||||||||||||||||
Examine the patient: ❑ Bradypnea/apnea ❑ Cyanosis nails and lips ❑ Decreased bowel sounds ❑ Decreased heart rate ❑ Decreased 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) ❑ Miosis ❑ Respiratory depression ❑ Stupor | |||||||||||||||||||||||||||||||||
Shown below is an alogorithm summarizing the basic approach to naloxone (Narcan) administration:
| 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 | Observe | |||||||||||||||||||||||||||||||||||||||
| Administer additional naloxone IV 15 mg Increase in respiratory rate? | |||||||||||||||||||||||||||||||||||||||||
Shown below is an algorithm summarizing the comprehensive approach to ICU management of patients with opioid overdose:[1]
| 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 | ||||||||||||||||||||||||||||