Paediatric Opioid Overdose

Question 1

When do we transport opioid toxicity pts

Answer 1

Any of :
- unable to maintain own airway
- spO2 < 92% RA
- age < 12 or > 65
- suspected aspiration
- APO
- Incomplete response post 2 doses of naloxone
- suspected opioid other than heroin including synthetic opioids
- pregnancy

Question 2

When are Opioid OD pts suitable for referral

Answer 2

• IV opioid only
• Normal VSS incl. GCS 15
• spO2 ≥92% RA
• Chest clear on auscultation
• Competent Adult available to supervise for 4/24.

Question 3

Toxicity is more likely when:

Answer 3

The patient is opioid naïve, elderly, or frail
A sedative is co-ingested
High-potency synthetic opioids are taken

Question 4

Signs of opioid toxicity

Answer 4

Respiratory depression (SpO2 < 92% on room air) / apnoea
Unable to maintain airway
CNS depression (ranging from drowsiness to coma)
Miosis
- Common but not always present
- Other substances that enlarge pupils (e.g.
amphetamines) may have also been taken. Many
non-opioid substances also cause miosis and may be
mistaken for opioid poisoning.
Prolonged QT interval (possible in methadone, oxycodone, loperamide)

Question 5

Complications of opioid toxicity

Answer 5

Aspiration pneumonitis
Pressure injury / rhabdomyolysis
Cardiac arrest due to prolonged hypoxia

Question 6

Differential diagnosis

Answer 6

Consider other causes of altered conscious state: i.e. AEIOUTIPS
A Alcohol / drug intoxication
E Epilepsy (post-ictal)
I Insulin or other metabolic cause – hypoglycaemia
O Overdose / oxygen (hypoxia)
U Underdose (including alcohol / drug withdrawal)
T Trauma (head trauma)
I Infection / sepsis
P Pain / psychiatric condition
S Stroke / TIA

Question 7

Isolated Heroin Toxicity

Answer 7

Rebound toxicity and other complications are less likely.
If there is a complete reversal of opioid effects, many patients in this group may be able to be safely
left with family, friends, or a carer with advice to:
Observe the patient for at least 4 hours
Administer take-home naloxone (if available) and call 000 if re-sedation occurs

Question 8

Other opioid toxicity

Answer 8

Refers to forms of opioid toxicity other than from isolated IV opioid administration e.g.:
- Prescription opioid use (e.g. oxycodone, morphine, codeine, transdermal fentanyl, buprenorphine, methadone)
- Polydrug toxicity involving any opioid including heroin (e.g. fentanyl and methamphetamine)
- Iatrogenic opioid toxicity (i.e. secondary to opioid analgesia)
- Unknown cause of opioid toxicity (i.e. heroin not suspected)

Question 9

Why is rebound toxicity rare, but possible in the other opioid pts?

Answer 9

due to the relatively short half-life of
naloxone compared to many opioids