Opioid toxicity: Difference between revisions
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===Common=== | ===Common=== | ||
*Miosis | *Miosis | ||
* | *[[Nausea/vomiting]] | ||
*Respiratory depression | *Respiratory depression | ||
*Mental status depression | *Mental status depression | ||
===Uncommon=== | ===Uncommon=== | ||
*QT prolongation (methadone) | *[[QT prolongation]] ([[methadone]]) | ||
*Seizure (tramadol) | *[[Seizure]] ([[tramadol]]) | ||
*Acute lung injury | *Acute lung injury | ||
*Bowel obstruction, rupture (body packers) | *[[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> | *[[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 | **Within 2-4 hrs of overdose | ||
**Increased RR, cough, pink frothy sputum, CXR with b/l infiltrates | **Increased RR, cough, pink frothy sputum, CXR with b/l infiltrates | ||
Revision as of 17:21, 2 June 2016
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
- Nausea/vomiting
- 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
Narcan Prescription
- Many states (31) offer protection again criminal liability for prescribing and distributing naloxone to laypeople
| Manufacturer | Route and Dose | Cost/Dose |
|---|---|---|
| Adapt Pharma | Prefilled IN 4mg | $33 |
| Amphastar | Self-assemble IN 2mg | $33 |
| Hospira | Self-assemble IM 0.4mg | $15.83 |
| Kaleo | Autoinjector 0.4mg | $287.50 |
- Example Rx
- Naloxone 4mg/0.1mL prefilled syringe and intranasal atomizer device
- Deliver 1 spray to 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.