Adult Opioid Overdose Flashcards
Naloxone Presentation
0.4 mg in 1 mL glass ampoule
Naloxone Pharmacology
An opioid antagonist
Actions:
Prevents or reverses the effects of opioids
Naloxone Indications
Altered conscious state and respiratory depression secondary to administration of opioids or related drugs
Naloxone Contraindications
Nil
Naloxone Precautions
- If patient is known to be physically dependent on opioids, be prepared for a combative patient after administration
- Neonates
Naloxone Side Effects
Symptoms of opioid withdrawal:
- Sweating, goose flesh, tremor
- Nausea and vomiting
- Agitation
- Dilatation of pupils, excessive lacrimation
- Convulsions
Naloxone Onset/Duration/Peak Times
IV effects:
Onset: 1 – 3 minutes
Peak: n/a
Duration: 30 – 45 minutes
IM effects:
Onset: 1 – 3 minutes
Peak: n/a
Duration: 30 – 45 minutes
Why is repeated doses of Naloxone often required?
The duration of action of Naloxone is often less than that of the opioid used, therefore repeated doses may be required.
The ‘Other opioid overdose’ arm of Overdose CPG should be used for:
- Prescription opioid medication overdose (e.g. oxycodone, morphine, codeine, fentanyl patches, methadone)
- Iatrogenic opioid overdose (e.g. secondary to opioid analgesia
- Polypharmacy overdose involving opioids (e.g. opioid and methamphetamine)
- Unknown cause of opioid overdose (heroin not suspected)
Mgx of Other Opioid OD for SD3
- R+R
- Position - Supine with Triple Airway Manouvre - MICA UNWELL PT
- ??O2 Therapy if poor TV - 100% via BVM RR12-16 aiming for adequate chest rise and fall - CONSIDER SGA IF >10/60 from hospital
- IV Access
- IV Naloxone 0.4mg/1mL (400mcg) - Dilute with 3mL NS 100mcg/1mL - Can repeated 100mcg ever 2/60 until pt self ventilating to a max of 2mg
- If unable to insert IV - 400mcg Naloxone IM once only
- MICA - up/downgrade/cancel/sitrep
- Extrication - combi to the stretcher - 2nd crew for extrication?
- Reassess 5/60 VSS
- Load Signal ? MICA ?
Differential Diagnosis for Other Opioid OD
Opioid OD - Other
Seizure - Post Ictal
Hypoglycaemia
Head Injury
Polypharmacy OD
Differential Diagnosis for Other Opioid OD
Opioid OD - Other
Seizure - Post Ictal
Hypoglycaemia
Head Injury
Polypharmacy OD
Why does the management of an Endone overdose differ from that of a Heroin Overdose?
Long-acting opioid medications; such as Endone generally have very long half-lives of 12 hours or more; as they are intended to provide long-term pain relief
- The intention of administering titrated IV doses of Naloxone is to restore adequate spontaneous ventilations so as to allow the patient to be safely transported to hospital for further management whilst not removing therapeutic benefits
In the setting of an opioid overdose with a concurrent head injury, should naloxone be administered? Provide a rational for your answer.
Patients who have sustained a head injury may receive opioid administration by either MICA Paramedics or hospitals to facilitate advanced airway management (ie intubation)
Therefore, as Naloxone is an opioid antagonist, it may prevent or reverse the effects of the opioids and should not be administered
With regard to medication dosage, what considerations would you have when attending a patient who has taken an overdose of synthetic opioids? (FENTANYL)
These may require higher than usual doses of Naloxone to reverse their effects
What complications may arise from Narcotic OD?
CNS depression
Ventilator failure
Aspiration
Seizures
CVS abnormalities - ECG abnormalities
Hypoxia
Disordered temperature regulation
Hypo/hyperthermia
Rhabdomyolysis
MSOF (multisystem organ failure)
Dangers to paramedics/bystanders
Heroin OD Differential Diagnosis
Heroin
Other Opioid OD
Seizure
Hypoglycaemia
Head Injury
Heroin SD3 Management
- R+R
- Position - Supine with Triple Airway Manouvre - MICA UNWELL PT
- Airway management - Consider airway adjuncts OPA/NPA
- ??O2 Therapy if poor TV - 100% via BVM RR12-16 aiming for adequate chest rise and fall - titrate to 92-96% once haemodynamically stable
- IM Naloxone 0.4mg/1mL (400mcg) - Dose 1.6mg/4mL or 2mg/5mL, large muscle mass - single dose only
- If inadequate response after 10/60 notification and Tx without delay - SGA if Tx >10/60
- MICA - up/downgrade/cancel/sitrep
- Extrication - combi to the stretcher - 2nd crew for extrication?
- Reassess 5/60 VSS
- Load Signal ? MICA ?
Would the application of the Treat and Refer guideline be appropriate if your patient had overdosed on both Heroin and Diazepam?
- Naloxone reverses the effect of heroin by binding to opioid receptors
- It has no effect on the reversal of the side effects on diazepam
- Patients who have taken an overdose of both heroin and diazepam are unlikely to
return to their full conscious state - Consequently, this guideline is not appropriate to use in this context.
In terms of pharmacology and medication half-life, why can it be unsafe to implement the Treat and Refer guideline for a heroin overdose?
- The IM dose of naloxone competitively binds to opioid receptors reversing the effects of the heroin
- As the naloxone wears off, heroin may still be active however the peak half-life has passed
- Therefore, subsequent relapse into respiratory depression and altered conscious state
is possible
What are two examples of prescription opioids?
Oxycodone
Morphine
Codeine
Fentanyl Patches
Methadone
Opioid OD Pharmacology
Opioids modulate nociception in the terminals of afferent nerves in the CNS, PNS and GI tract
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Antagonist at the μ (OP3), κ (OP2) and δ (OP1) receptors
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OP3 receptors divide into two subtypes which result in analgesia, respiratory depression, cough suppression and euphoria
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OP3a has the most analgesic effect; OP3b results in respiratory depression
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OP2 results in spinal analgesia, miosis (pin point pupils) and diuresis
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OP1 effects are largely unknown
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There is a localised release of dopamine in the mesolimbic pathway (“pleasure pathway” resulting in euphoria) common to almost all OP3 and OP1 opioids
When can Heroin OD pt be left at home (Treat and Refer Assess CPG)
- Pt chest clear on auscultation
- Pt SpO2 >94% on RA
- Pt fully recovered, low risk able to be monitored for 4/24 by a responsible adult
