Opioid toxicity
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)
Clinical Features
- Common
- Miosis
- N/V
- Respiratory depression
- Mental status depression
- Uncommon
- QT prolongation (methadone)
- Seizure (tramadol)
- Acute lung injury
Differential Diagnosis
- Clonidine toxicity
- Organophosphate toxicity
- CO poisoning
- Hypoglycemia
- Postictal state
- CVA
Sedative/hypnotic toxicity
- Absinthe
- Barbiturates
- Benzodiazepines
- Chloral hydrate
- Gamma hydroxybutyrate (GHB)
- Baclofen toxicity
- Opioids
- Toxic alcohols
- Xylazine toxicity
Treatment
- Airway protection and ventilatory management
- BVM and naloxone administration may prevent need for intubation
- Naloxone (Narcan)
- Alsmost immediate onset of action
- Dosing
- Bolus (May repeat q3min up to max dose 10mg
- Apneic or near-apneic - 2mg IV
- Opioid-naive with minimal respiratory depression - 0.4mg IV
- Opioid-dependent with minimal respiratory depression - 0.05mg IV
- Duration of action = 20-90min (may be less than that of the ingested opioid)
- Infusion
- Only give if the pt 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
- Bolus (May repeat q3min up to max dose 10mg
- GI decontamination
- Activated charcoal x1 if opioid ingestion occurred within 1hr
Disposition
- Heroin intoxication:
- Consider discharge 1-2hr after naloxone administration if all are true:
- Independent mobility
- O2 sat >92% (room air)
- RR >10bpm
- HR >50
- Normal temp
- GCS 15
- Consider discharge 1-2hr after naloxone administration if all are true:
- Non-heroin intoxication:
- Consider discharge after 4-6hr obs
See Also
External Links
- http://www.mdcalc.com/opioid-risk-tool-ort-for-narcotic-abuse/ MDCalc - Opiod Risk Tool (ORT) for Narcotic Abuse
Source
- ↑ 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.