Opioid toxicity

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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

Sedative/hypnotic 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

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

  1. 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.
  2. Sporer KA and Dorn E. Heroin-related noncardiogenic pulmonary edema: a case series. Chest. 2001; 120(5):1628-32.