Adult Opioid Overdose

Question 1

Naloxone Presentation

Answer 1

0.4 mg in 1 mL glass ampoule

Question 2

Naloxone Pharmacology

Answer 2

An opioid antagonist
Actions:
Prevents or reverses the effects of opioids

Question 3

Naloxone Indications

Answer 3

Altered conscious state and respiratory depression secondary to administration of opioids or related drugs

Question 4

Naloxone Contraindications

Answer 4

Nil

Question 5

Naloxone Precautions

Answer 5

1. If patient is known to be physically dependent on opioids, be prepared for a combative patient after administration
2. Neonates

Question 6

Naloxone Side Effects

Answer 6

Symptoms of opioid withdrawal:
- Sweating, goose flesh, tremor
- Nausea and vomiting
- Agitation
- Dilatation of pupils, excessive lacrimation
- Convulsions

Question 7

Naloxone Onset/Duration/Peak Times

Answer 7

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

Question 8

Why is repeated doses of Naloxone often required?

Answer 8

The duration of action of Naloxone is often less than that of the opioid used, therefore repeated doses may be required.

Question 9

The ‘Other opioid overdose’ arm of Overdose CPG should be used for:

Answer 9

• 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)

Question 10

Mgx of Other Opioid OD for SD3

Answer 10

1. R+R
2. Position - Supine with Triple Airway Manouvre - MICA UNWELL PT
3. ??O2 Therapy if poor TV - 100% via BVM RR12-16 aiming for adequate chest rise and fall - CONSIDER SGA IF >10/60 from hospital
4. IV Access
5. 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
6. If unable to insert IV - 400mcg Naloxone IM once only
7. MICA - up/downgrade/cancel/sitrep
8. Extrication - combi to the stretcher - 2nd crew for extrication?
9. Reassess 5/60 VSS
10. Load Signal ? MICA ?

Question 11

Differential Diagnosis for Other Opioid OD

Answer 11

Opioid OD - Other
Seizure - Post Ictal
Hypoglycaemia
Head Injury
Polypharmacy OD

Question 12

Differential Diagnosis for Other Opioid OD

Answer 12

Opioid OD - Other
Seizure - Post Ictal
Hypoglycaemia
Head Injury
Polypharmacy OD

Question 13

Why does the management of an Endone overdose differ from that of a Heroin Overdose?

Answer 13

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

Question 14

In the setting of an opioid overdose with a concurrent head injury, should naloxone be administered? Provide a rational for your answer.

Answer 14

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

Question 15

With regard to medication dosage, what considerations would you have when attending a patient who has taken an overdose of synthetic opioids? (FENTANYL)

Answer 15

These may require higher than usual doses of Naloxone to reverse their effects

Question 16

What complications may arise from Narcotic OD?

Answer 16

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

Question 17

Heroin OD Differential Diagnosis

Answer 17

Heroin
Other Opioid OD
Seizure
Hypoglycaemia
Head Injury

Question 18

Heroin SD3 Management

Answer 18

1. R+R
2. Position - Supine with Triple Airway Manouvre - MICA UNWELL PT
3. Airway management - Consider airway adjuncts OPA/NPA
4. ??O2 Therapy if poor TV - 100% via BVM RR12-16 aiming for adequate chest rise and fall - titrate to 92-96% once haemodynamically stable
5. IM Naloxone 0.4mg/1mL (400mcg) - Dose 1.6mg/4mL or 2mg/5mL, large muscle mass - single dose only
6. If inadequate response after 10/60 notification and Tx without delay - SGA if Tx >10/60
7. MICA - up/downgrade/cancel/sitrep
8. Extrication - combi to the stretcher - 2nd crew for extrication?
9. Reassess 5/60 VSS
10. Load Signal ? MICA ?

Question 19

Would the application of the Treat and Refer guideline be appropriate if your patient had overdosed on both Heroin and Diazepam?

Answer 19

• 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.

Question 20

In terms of pharmacology and medication half-life, why can it be unsafe to implement the Treat and Refer guideline for a heroin overdose?

Answer 20

• 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

Question 21

What are two examples of prescription opioids?

Answer 21

Oxycodone
Morphine
Codeine
Fentanyl Patches
Methadone

Question 22

Opioid OD Pharmacology

Answer 22

Opioids modulate nociception in the terminals of afferent nerves in the CNS, PNS and GI tract
↓
Antagonist at the μ (OP3), κ (OP2) and δ (OP1) receptors
↓
OP3 receptors divide into two subtypes which result in analgesia, respiratory depression, cough suppression and euphoria
↓
OP3a has the most analgesic effect; OP3b results in respiratory depression
↓
OP2 results in spinal analgesia, miosis (pin point pupils) and diuresis
↓
OP1 effects are largely unknown
↓
There is a localised release of dopamine in the mesolimbic pathway (“pleasure pathway” resulting in euphoria) common to almost all OP3 and OP1 opioids

Question 23

When can Heroin OD pt be left at home (Treat and Refer Assess CPG)

Answer 23

• 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