Opioid Overdoses – Management
Special Populations, Toxicology
- Ultrapotent opioids such as fentanyl are now ubiquitous. Opioid overdoses are becoming increasingly common and represented almost half of illicit overdose deaths in 2016.
Signs and Symptoms
- Usually presents as sedation, miosis with progression to respiratory depression, coma and death.
- Less commonly chest wall rigidity (fentanyl and derivatives), acute lung injury, QT prolongation and Torsades de Pointes.
- Rapid onset following IV injection or insufflation.
- Peak effect within 1 hour of ingesting regular-release products or crushed/adulterated sustained-release tablets.
- May be significantly delayed with massive ingestion and sustained-release products.
- Absorption may be delayed up to 24 hours with ingested fentanyl patches.
Duration of Action
- The duration of action depends on dose, ongoing absorption, and the half-life
- Duration of action in overdose can be significantly longer than therapeutic dosing.
- Short/moderate half-life (2-4 hours):
- meperidine, and
- fentanyl* (duration of action of fentanyl may exceed 24 hours in overdose).
- Long half-life (>12 hours):
- Oral extended-release preparations.
- Opioid toxidrome, history of drug use, paraphernalia found with the patient, and response to naloxone.
- Do not induce vomiting.
- Supplemental oxygen with assisted ventilations as required.
- Consider activated charcoal if ingested within 1-2 hours and there is no concern for aspiration.
- Protect airway as needed.
- Hypotension typically responds to IV fluids.
- Chest x-ray if persistent low O2 sats, abnormal chest sounds or fever.
- Obtain an EKG to rule out significant QT prolongation or other dysrhythmias if methadone or loperamide is suspected.
- Call the poison centre if there are any management or diagnostic questions.
- Offer patients take-home naloxone and access to addictions services at discharge.
Indications for naloxone:
- Respiratory rate < 10 /min OR
- Saturation < 92% on room air, inability of patient to protect their airway OR,
- Fentanyl induced chest wall rigidity.
Goals of naloxone:
- RR ≥ 10/min,
- GCS > 10,
- Protecting airway,
- No acute withdrawal symptoms precipitated.
Routes: IV/IO preferred. IM/SC otherwise.
- Adults: 0.1 mg IV/IO or 0.4 mg IM if no IV/IO
- Pediatrics: 0.1 mg/kg IV/IO/IM of body weight
- If insufficient response, subsequent IV doses should be administered every 2 minutes (q3 minutes IM): 0.4 mg, 2.0 mg, 4.0 mg, and then 10 mg as a final dose if there is a high clinical suspicion of opioid intoxication.
- If no response, look for alternate causes for symptoms.
- Consider infusion if there is recurrence of symptoms.
- Bolus, then 0.4-0.8 mg/hr. titrated to clinical effect.
- Infants = 0.04-0.16 mg/kg/hr.
- Alternatively, administer two-thirds of the initial effective bolus dose per hour to keep the patient alert.
- Asymptomatic patients who have ingested opiate and NOT received naloxone:
- Monitor for 4 hours following regular release opioids and 12 hours following ingestion of sustained release opioids or methadone.
- Lower risk patients:
- Did not require more than 0.9 mg naloxone for reversal.
- Opioid smoked, insufflated or injected (not ingested).
- Did not require repeat doses or infusion of naloxone.
- Observe for a minimum of 2 hours following naloxone administration.
- Higher risk patients:
- Oral overdose
- More than 0.9 mg of naloxone required for reversal.
- Observe for a minimum of 6 hours following last dose of naloxone.
- Naloxone infusion: Observe for at least 12 hours after naloxone infusion has been stopped.
Criteria For Safe Discharge Home
- Awake, alert with normal vital signs and oxygen saturation on room air and can mobilize as usual without verbal or physical stimulation.
Criteria For Hospital Admission
- Acute lung injury,
- Inadequate response to antidote therapy,
- Ongoing naloxone infusion needed.
Criteria For Transfer To Another Facility
- If patient requires ICU care not available locally.
- BC Drug and Poison Information Centre 604-682-5050, or 1-800-567-8911.
- Consult should be obtained for all pediatric or body packing/stuffing exposures as well as any supratherapeutic exposure to methadone, buprenorphine or fentanyl patches.
Quality Of Evidence?
We are highly confident that the true effect lies close to that of the estimate of the effect. There is a wide range of studies included in the analyses with no major limitations, there is little variation between studies, and the summary estimate has a narrow confidence interval.
We consider that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. There are only a few studies and some have limitations but not major flaws, there are some variations between studies, or the confidence interval of the summary estimate is wide.
When the true effect may be substantially different from the estimate of the effect. The studies have major flaws, there is important variations between studies, of the confidence interval of the summary estimate is very wide.
Case reports, case series and retrospective chart reviews.
OTHER RELEVANT INFORMATION
Take Home Naloxone – www.naloxonetraining.com
Tool for patients to learn how to use a Take Home Naloxone Kit. It can also be used in centres where staff members are not very familiar with dispensing a THN kit. (St. Paul’s Hospital ED Project).
UBC Department of Emergency Medicine Grand Rounds – Dec. 13, 2017
Information about harm reduction and take home naloxone – towardtheheart.com
The purpose of this document is to provide health care professionals with key facts and recommendations for the diagnosis and treatment of patients in the emergency department. This summary was produced by the BC Emergency Medicine Network and uses the best available knowledge at the time of publication. However, healthcare professionals should continue to use their own judgment and take into consideration context, resources and other relevant factors. The BC Emergency Medicine Network is not liable for any damages, claims, liabilities, costs or obligations arising from the use of this document including loss or damages arising from any claims made by a third party. The BC Emergency Medicine Network also assumes no responsibility or liability for changes made to this document without its consent.
Last Updated Oct 23, 2017
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