Opioid toxicity

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)
• Consider contributing to the DAWN database for public ED research benefit (Drug Abuse Warning Network)

Clinical Features

1. Common
   1. Miosis
   2. N/V
   3. Respiratory depression
   4. Mental status depression
2. Uncommon
   1. QT prolongation (methadone)
   2. Seizure (tramadol)
   3. Acute lung injury

DDX

1. Clonidine toxicity
2. Organophosphate toxicity
3. Sedative-hypnotic toxicity
4. CO poisoning
5. Hypoglycemia
6. Postictal state
7. CVA

Treatment

1. Airway protection and ventilatory management
   1. BVM and naloxone administration may prevent need for intubation
2. Naloxone
   1. Characteristics
      1. Onset of action - 1-2min
      2. Duration of action - 20-90min (may be less than that of the ingested opioid)
   2. Dosing
      1. Bolus (May repeat q3min up to max dose 10mg
         1. Apneic or near-apneic - 2mg IV
         2. Opioid-naive with minimal respiratory depression - 0.4mg IV
         3. Opioid-dependent with minimal respiratory depression - 0.05mg IV
      2. Infusion
         1. Only give if the pt responded to the bolus and required repeat administration
         2. Step 1: Determine the "wake-up dose" or bolus required to wake the pt
         3. Step 2: Give 2/3 of the "wake-up dose" per hr; mix in 1L D5W
      3. Side Effects
         1. Mostly related to causing opioid withdrawal
         2. Serious complications are rare
3. GI decontamination
   1. Activated charcoal x1 if opioid ingestion occurred within 1hr

Disposition

1. Heroin intoxication:
   1. Consider discharge 1-2hr after naloxone administration if all are true:
      1. Independent mobility
      2. O2 sat >92% (room air)
      3. RR >10bpm
      4. HR >50
      5. Normal temp
      6. GCS 15
2. Non-heroin intoxication:
   1. Consider discharge after 4-6hr obs

External Links

• [http://www.mdcalc.com/opioid-risk-tool-ort-for-narcotic-abuse/ MDCalc - Opiod Risk Tool (ORT) for Narcotic Abuse

Source

• Tintinalli