10/19/2023 Opioid OD

You have a 30 y/o male in EM1 with R knee pain. He was diagnosed with a knee strain and was being discharged. You are called back to the room after the nurse went to discharge the patient and he was found unresponsive.

What are your next steps?

You evaluate the patient’s ABCs. He is unresponsive with GCS 3. He does not have breath sounds bilaterally and he does have palpable pulses. While you are assessing his ABCs, he is placed on the monitor and is hypoxic to 60%.

His other vital signs: BP 90/60, HR 52, R 0, T 98.6F

What do you do next?

You start bagging the patient, and you ask the nurse to obtain a POC glucose. If you have not done so already, you call for help from your attending, additional nurses, and RT. You do a quick physical exam and notice pinpoint pupils bilaterally. You call for Narcan…

After several stressful seconds, the patient becomes responsive and starts to breath on his own after Narcan.

Repeat vital signs: BP 110/60, HR 75, RR 16, T 98.6F

You observe the patient in the ED without issues and he is discharged home.

Case Discussion

This is a case of a low-acuity patient who has a rapid change in clinical status while in the ED. This is inherently a stressful event and can be exacerbated by being in a clinical space outside of TCC. However, you have all the tools to handle this! Go back to your basics: ABCs and IV/O2/monitor. Obtain a full set of vital signs and a POC glucose to begin with. There are several mnemonics out there to help you remember some of these critical initial steps with altered mental status. One of those is DON’T (be stupid):

Dextrose

Oxygen

Narcan

Thiamine

Another important initial consideration in this patient is cardiac etiology as he was bradycardic and hypotensive. An EKG should be obtained as soon as possible, and defibrillation pads placed on the patient.

In this case, the patient’s unresponsiveness was caused by an opioid overdose. Acute opioid overdoses present with respiratory depression, changes in mental status, and miosis. Narcan is indicated in patients whose opioid overdose is affecting their respiratory status.

Narcan dosing:

• Apneic: 2mg IV or IN

• Opioid-naïve: 0.4mg IV

• Opioid-dependent: 0.04-0.1mg IV

• The goal in this population is to improve their respiratory depression

  without putting them into precipitated withdrawal

Caveat: There are many different algorithms and practice patterns for Narcan dosing (see EmCrit blog post below), but the above doses are good starting points.

The maximum dose of Narcan is 10mg. Its onset is almost immediate, and it lasts for 20-90 minutes. These patients need to be closely monitored as some opioids last longer than the Narcan. If patients require and are responsive to repeated doses of Narcan, you should consider starting the patient on a Narcan drip. The dosing is 2/3 of the “wake-up dose” per hour.

If the patient does not require multiple doses, how long do you observe them in the Emergency Department? There are varying opinions and practice patterns on this. Lucky for us, our esteemed toxicology colleagues have studied and published on this topic. It is reasonable to discharge these patients after 1-2 hours of observation if they have normal vital signs and mental status with GCS 15 (Willman et al., 2017)

Latent Safety Threats (LST)

The team did an excellent job of recognizing abnormal vital signs and initiating treatment for an opioid overdose. The LSTs from this case revolve around delays in care due to lack of available equipment (BVM, cardiac pads, etc.). If you think there’s even a chance you may need resuscitative equipment in a pod outside of TCC, call for it to bedside early. Don’t be afraid to call for additional help early from your colleagues as well!

References:

• https://emcrit.org/ibcc/opioid/

• Jordan MR, Morrisonponce D. Naloxone. [Updated 2023 Apr 29]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from https://www.ncbi.nlm.nih.gov/books/NBK441910/

• Willman MW, Liss DB, Schwarz ES, Mullins ME. Do heroin overdose patients require observation after receiving naloxone? Clin Toxicol (Phila). 2017 Feb;55(2):81-87. doi: 10.1080/15563650.2016.1253846. Epub 2016 Nov 16. PMID: 27849133.

• Images: How Does Narcan Work? Naloxone Uses And Contraindications (addictionresource.com)