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

Further 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