Opioid overdose resident survival guide

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

Overview

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 ❑ Seizure ❑ 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) ❑ Miosis ❑ Respiratory depression (Rate < 12/min) ❑ Stupor

Initial Management

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

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:

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

• 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.
• Consider gastric decontamination with activated charcoal if the patient presents within 1 hour of overdose.

Dont's

• Do not rely on miosis as the sole criteria for diagnosis of opioid overdose, as poisoning from meperidine, propoxyphene, or tramadol can cause mydriasis.
• Do not wait for or rely on urine toxicology screens, to administer naloxone.
• Do not manage cases developing pulmonary edema by using diuretics, it is likely to worsen myoglobinuric renal failure.
• Do not discharge patient immediately after reversal of respiratory depression, as it does not necessarily co-relate with peak of opioid concentration.