Opioid toxicity: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
===Common=== | ===Common=== | ||
*Miosis | |||
*N/V | |||
*Respiratory depression | |||
*Mental status depression | |||
===Uncommon=== | ===Uncommon=== | ||
*QT prolongation (methadone) | |||
*Seizure (tramadol) | |||
*Acute lung injury | |||
*Bowel obstruction, rupture (body packers) | |||
*Noncardiogenic pulmonary edema (1-2% of heroin overdoses)<ref>Sporer KA and Dorn E. Heroin-related noncardiogenic pulmonary edema: a case series. Chest. 2001; 120(5):1628-32.</ref> | |||
**Within 2-4 hrs of overdose | |||
**Increased RR, cough, pink frothy sputum, CXR with b/l infiltrates | |||
**Resolves in 24-48 hrs with respiratory supportive care | |||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
| Line 53: | Line 53: | ||
==Disposition== | ==Disposition== | ||
===Heroin intoxication=== | ===Heroin intoxication=== | ||
*Can consider discharge 1-2hr after naloxone administration if all are true: | |||
**Ambulatory without assistance | |||
**O2 sat >92% (room air) | |||
**RR >10bpm | |||
**HR >50 | |||
**Normal temp | |||
**GCS 15 | |||
===Non-heroin intoxication=== | ===Non-heroin intoxication=== | ||
*Consider discharge after 4-6hr obs | |||
*Consider discharge with prescription for [[Naloxone]] depending on your jurisdiction | |||
**Naloxone 2 mg/2 mL prefilled syringe and intranasal atomizer device with instructions: ''to spray one-half of syringe (1 mL) into each nostril upon signs of opioid overdose. May repeat X 1. Call 911.'' | |||
==See Also== | ==See Also== | ||
| Line 71: | Line 71: | ||
*[http://www.mdcalc.com/opioid-risk-tool-ort-for-narcotic-abuse/ MDCalc - Opiod Risk Tool (ORT) for Narcotic Abuse] | *[http://www.mdcalc.com/opioid-risk-tool-ort-for-narcotic-abuse/ MDCalc - Opiod Risk Tool (ORT) for Narcotic Abuse] | ||
== | ==References== | ||
<references/> | <references/> | ||
[[Category:Tox]] | [[Category:Tox]] | ||
Revision as of 22:36, 27 October 2015
Background
- Obtain acetaminophin levels in all cases of combination opioid-acetaminophen overdoses
- Respiratory depression is the cause of all mortality from opioid toxicity
- When prescribing opioid pain relievers in the ED, remember to have a discussion of co-ingestion of other depressants (alcohol involved in 1/5 of opioid related deaths)[1]
- Consider contributing to the DAWN database for public ED research benefit (Drug Abuse Warning Network)
- Other than common co-ingestions, consider adulterants such as amphetamines, anticholinergics, hypnotics, heavy metals, etc.
Clinical Features
Common
- Miosis
- N/V
- Respiratory depression
- Mental status depression
Uncommon
- QT prolongation (methadone)
- Seizure (tramadol)
- Acute lung injury
- Bowel obstruction, rupture (body packers)
- Noncardiogenic pulmonary edema (1-2% of heroin overdoses)[2]
- Within 2-4 hrs of overdose
- Increased RR, cough, pink frothy sputum, CXR with b/l infiltrates
- Resolves in 24-48 hrs with respiratory supportive care
Differential Diagnosis
- Clonidine toxicity
- Organophosphate toxicity
- CO poisoning
- Hypoglycemia
- Postictal state
- CVA - pontine hemorrhage (miosis, coma)
- ARDS
- DKA, hyperosmolar coma
Sedative/hypnotic toxicity
- Absinthe
- Barbiturates
- Benzodiazepines
- Chloral hydrate
- Gamma hydroxybutyrate (GHB)
- Baclofen toxicity
- Opioids
- Toxic alcohols
- Xylazine toxicity
- Phencyclidine toxicity
- Phenothiazine toxicity
Treatment
Airway protection and ventilatory management
- BVM and naloxone administration may prevent need for intubation
Naloxone (Narcan)
May repeat Naloxone q3min up to max dose 10mg. It has an almost immediate onset of action with a duration of action = 20-90min (depending on the drug ingested, most overdoses especially from heroin will require repeat dosing of Naloxone)
Dosing
- If apneic or near-apneic - 2mg IV
- If opioid-naive with minimal respiratory depression - 0.4mg IV
- If opioid-dependent with minimal respiratory depression - 0.05mg IV
- Infusion
- Only give if the patient responded to the bolus and required repeat administration
- Step 1: Determine the "wake-up dose" or bolus required to wake the pt
- Step 2: Give 2/3 of the "wake-up dose" per hr; mix in 1L D5W
GI decontamination
- Activated charcoal x1 if opioid ingestion occurred within 1hr
Disposition
Heroin intoxication
- Can consider discharge 1-2hr after naloxone administration if all are true:
- Ambulatory without assistance
- O2 sat >92% (room air)
- RR >10bpm
- HR >50
- Normal temp
- GCS 15
Non-heroin intoxication
- Consider discharge after 4-6hr obs
- Consider discharge with prescription for Naloxone depending on your jurisdiction
- Naloxone 2 mg/2 mL prefilled syringe and intranasal atomizer device with instructions: to spray one-half of syringe (1 mL) into each nostril upon signs of opioid overdose. May repeat X 1. Call 911.
See Also
External Links
References
- ↑ Jones CM, Paulozzi LJ, Mack KA. Alcohol Involvement in Opioid Pain Reliever and Benzodiazepine Drug Abuse–Related Emergency Department Visits and Drug-Related Deaths — United States, 2010. CDC MMWR. October 10, 2014 / 63(40);881-885.
- ↑ Sporer KA and Dorn E. Heroin-related noncardiogenic pulmonary edema: a case series. Chest. 2001; 120(5):1628-32.