11/13/24, 7\:37 PM Guide | Opioid overdose
Opioid overdose
Table of contents
Introduction
This guide provides an overview of the recognition and immediate management of opioid overdose using an ABCDE
approach.
The ABCDE approach is used to systematically assess an acutely unwell patient. It involves working through the following
steps\:
Airway
Breathing
Circulation
Disability
Exposure
Each stage of the ABCDE approach involves clinical assessment, investigations and interventions. Problems are addressed
as they are identi
This guide has been created to assist healthcare students in preparing for emergency simulation sessions as part of their
training. It is not intended to be relied upon for patient care.
Opioids and opioid overdose
Opioid abuse is a signi
are attributed to drug use, with more than 21% attributed to opioid overdose.
The terms opiate and opioid are often used interchangeably. However, they have di
An opiate is a naturally occurring alkaloid drug derived from the opium poppy (e.g. morphine and codeine)
An opioid is any synthetic or semi-synthetic drug derived from the opium poppy (e.g. fentanyl and oxycodone)
Opioid is used as the broad term for any substance that binds opioid receptors to produce an opiate-like toxidrome.
Clinical features
The typical triad of features in an opioid overdose is\:
Decreased level of consciousness
Respiratory depression
Pin-point pupils (miosis)
Other symptoms may include\:
Nausea
Vomiting
Confusion
Suspecting an opioid overdose
Opioid overdose can occur in several distinct patient groups\:
Individuals with a history of drug use
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Patients who have been prescribed opioid medications, including those currently admitted to hospital\: especially
elderly patients and those with reduced renal function
Cases of deliberate self-harm
It is crucial to always consider the possibility of opioid overdose in any patient presenting with a reduced level of
consciousness.
Tips before you begin
General tips for applying an ABCDE approach in an emergency setting include\:
Treat problems as you discover them
Re-assess regularly and after every intervention to monitor a patient’s response to treatment
If the patient loses consciousness and there are no signs of life, put out a crash call and commence CPR
Make use of the team around you by delegating tasks where appropriate
All critically unwell patients should have continuous monitoring equipment attached
Clearly communicate how often you would like the patient’s observations relayed to you by other sta
If you require senior input, call for help early using an appropriate SBAR handover
Review results as they become available (e.g. laboratory investigations)
Use local guidelines and algorithms to manage speciacute asthma)
Any medications or must be prescribed at the time (you may be able to delegate this to another sta
Your assessment and management should be documented clearly in the notes. However, this should not
delay management. The A-E approach can also form the structure for documenting your assessment.
Initial steps
Acute scenarios typically begin with a brief handover, including the patient’s name, age, background and
the reason the review has been requested.
You may be asked to review a patient with opioid overdose due to agitation, bradypnoea and/or reduced level of
consciousness.
Introduction
Introduce yourself to whoever has requested a review of the patient and listen carefully to their handover.
Interaction
Introduce yourself to the patient, including your name and role.
Ask how the patient is feeling, as this may provide useful information about their current condition.
If the patient is unconscious or unresponsive, and there are no signs of life, start the basic life support (BLS) algorithm as per
resuscitation guidelines.
Preparation
Ensure the patient’s notes, observation chart, and prescription chart are easily accessible.
Ask for another clinical member of sta
Airway
Clinical assessment
Can the patient talk?
Yes\: if the patient can talk, their airway is patent, and you can move on to the assessment of breathing.
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No\:
Look for signs of airway compromise\: angioedema, cyanosis, see-saw breathing, use of accessory muscles
Listen for abnormal airway noises\: stridor, snoring, gurgling
Open the mouth and inspect\: look for anything obstructing the airway, such as secretions or a foreign object
Interventions
Regardless of the underlying cause of airway obstruction, seek immediate expert support from an anaesthetist and the
emergency medical team (often called the ‘crash team’). You can perform basic airway manoeuvres to help maintain the
airway whilst awaiting senior input.
Head-tilt chin-lift manoeuvre
Open the patient’s airway using a head-tilt chin-lift manoeuvre\:
1. Place one hand on the patient’s forehead and the other under the chin
2. Tilt the forehead back whilst lifting the chin forwards to extend the neck
3. Inspect the airway for obvious obstruction. If an obstruction is visible within the airway, use a
and remove it. Be careful not to push it further into the airway.
Jaw thrust
If the patient is suspected of having su
than a head-tilt chin-lift manoeuvre\:
1. Identify the angle of the mandible
2. Place two
3. Lift the mandible forwards
Other interventions
Airway adjuncts are helpful and, in some cases, essential to maintain a patient’s airway. They should be used in conjunction with
the manoeuvres mentioned above.
An oropharyngeal airway is a curved plastic tube with a
relieve soft palate obstruction. It should only be inserted in unconscious patients as it may induce gagging and aspiration in
semi-conscious patients.
A nasopharyngeal airway is a soft plastic tube with a bevel at one end and a
tolerated in partly or fully conscious patients than oropharyngeal airways.
Re-assessment
Make sure to re-assess the patient after any intervention.
Breathing
Clinical assessment
Observations
Review the patient’s respiratory rate\:
A normal respiratory rate is between 12-20 breaths per minute
Bradypnoea is a common clinical feature of an opioid overdose
Review the patient’s oxygen saturation (SpO )\:
2
A normal SpO 2 2
range is 94-98% in healthy individuals and 88-92% in patients with COPD at high risk of CO retention
Hypoxaemia may occur in opioid overdose due to respiratory depression
See our guide to performing observations/vital signs for more details.
Inspection
Inspect the patient from the end of the bed\:
Cyanosis\: bluish discolouration of the skin due to poor circulation or inadequate oxygenation
Auscultation
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Auscultate the chest to screen for evidence of other respiratory pathology (e.g. coarse crackles may be present if the patient
has developed aspiration pneumonia).
Investigations and procedures
Arterial blood gas
Take an ABG if indicated (e.g. low SpO ) to quantify the degree of hypoxia.
2
Patients may develop type 2 respiratory failure (i.e. low PaO 2 2
and raised CO ) following an opioid overdose due to respiratory
depression.
Chest X-ray
A chest X-ray may be indicated if abnormalities are noted on auscultation (e.g. reduced air entry, coarse crackles) to screen for
evidence of aspiration pneumonia. A chest X-ray should not delay the emergency management of opioid overdose.
See our CXR interpretation guide for more details.
Interventions
Ventilation
Respiratory depression is common in opioid overdose, which can lead to critical hypoxia. If breathing is inadequate (\<10
breaths per minute), support breathing with bag-valve-mask ventilation and call for senior clinical support.
Oxygen
Administer oxygen to all critically unwell patients during your initial assessment. This typically involves using a non-rebreathe
mask with an oxygen
Naloxone
Naloxone is used to treat opioid-induced respiratory depression by blocking the e
The initial dose is 400 micrograms IV. If there is no response, two subsequent doses of 800 micrograms can be given at 1-
minute intervals. Naloxone can also be administered via the subcutaneous or intramuscular route. However, the intravenous
route has the quickest onset of action.
Naloxone has a short half-life, and some patients may require a naloxone infusion after a discussion with a senior clinician.
Naloxone rapidly reverses the e
pain, confusion and agitation. Consider involving the drug and alcohol team to discuss appropriate opioid replacement
therapy to treat symptoms of withdrawal.
Re-assessment
Make sure to re-assess the patient after any intervention.
Circulation
Clinical assessment
Blood pressure
Hypotension is also a common clinical feature of opioid overdose.
Capillary re
Capillary re
Investigations and procedures
Intravenous cannulation
Insert at least one wide-bore intravenous cannula (14G or 16G) and take blood tests as discussed below.
See our intravenous cannulation guide for more details.
Blood tests
Request a full blood count (FBC), urea & electrolytes (U&E) and liver function tests (LFTs) for all acutely unwell patients. In
the context of an opioid overdose, also request\:
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CRP\: to screen for evidence of infection
Lactate\: to screen for evidence of reduced end-organ perfusion
Coagulation studies\: to screen for coagulopathy
Toxicology screen (including paracetamol levels)\: to screen for other drugs which may have been taken as part of a mixed
overdose
Interventions
Fluid resuscitation
Hypovolaemic patients require
Administer a 500ml bolus Hartmann’s solution or 0.9% sodium chloride (warmed if available) over less than 15 mins.
Administer 250ml boluses in patients at increased risk of
After each
Repeat administration of
reassessing the patient each time.
Seek senior input if the patient has a negative response (e.g. increased chest crackles) or isn’t responding adequately to
repeated boluses (i.e. persistent hypotension).
See our for more details on resuscitation
Re-assessment
Make sure to re-assess the patient after any intervention.
Disability
Clinical assessment
Consciousness
Reduced consciousness is a common feature of opioid overdose.
Assess the patient’s level of consciousness using the ACVPU scale\:
Alert\: the patient is fully alert
Confusion\: the patient has new onset confusion or worse confusion than usual
Verbal\: the patient makes some kind of response when you talk to them (e.g. words, grunt)
Pain\: the patient responds to a painful stimulus (e.g. supraorbital pressure)
Unresponsive\: the patient does not show evidence of any eye, voice or motor responses to pain
If a more detailed assessment of the patient’s level of consciousness is required, use the Glasgow Coma Scale (GCS).
Pupils
Assess the patient's pupils\:
Inspect the size and symmetry of the patient's pupils\: pin-point pupils are associated with opioid overdose
Assess direct and consensual pupillary responses\: pupillary re
Drug chart review
anxiolytics).
Review the patient's drug chart for medications which may cause neurological abnormalities (e.g. opioids, sedatives,
Investigations
Blood glucose and ketones
Measure the patient's capillary blood glucose level to screen for other causes of a reduced level of consciousness (e.g.
hypoglycaemia or hyperglycaemia).
A blood glucose level may already be available from earlier investigations (e.g. ABG, venepuncture).
The normal reference range for fasting plasma glucose is 4.0 – 5.8 mmol/l.
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Hypoglycaemia is de≤4.0
mmol/L should be treated if the patient is symptomatic.
If the blood glucose is elevated, check ketone levels which, if also elevated, may suggest a diagnosis of diabetic ketoacidosis
(DKA).
See our blood glucose measurement, hypoglycaemia and diabetic ketoacidosis guides for more details.
Imaging
Request a CT head if intracranial pathology is suspected after discussion with a senior clinician.
See our guide on interpreting a CT head for more details.
Interventions
Maintain the airway
Alert a senior clinician immediately if you have concerns about a patient’s consciousness level.
A GCS of 8 or below, or a P or U on the ACVPU scale, warrants urgent expert help from an anaesthetist. In the meantime, you
should re-assess and maintain the patient’s airway, as explained in the airway section of this guide.
Correct hypoglycaemia
Hypoglycaemia should always be considered in patients presenting with a reduced level of consciousness, regardless of
whether they have diabetes. The management of hypoglycaemia involves the administration of glucose (e.g. oral or
intravenous).
See our hypoglycaemia guide for more details.
Re-assessment
Make sure to re-assess the patient after any intervention.
Exposure
Exposing the patient during your assessment may be necessary. Remember to prioritise patient dignity and the conservation
of body heat.
Clinical assessment
Inspection
Inspect the patient's skin for evidence of medication patches (Figure 1), injection sites, injuries or infection (e.g. erythema).
Review the output of the patient's catheter and any surgical drains.
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Figure 1. A fentanyl transdermal patch on the inner arm
Temperature
Measure the patient’s temperature\:
If fever is present, consider co-existing infection (e.g. infective endocarditis is more common in intravenous drug users)
Interventions
Remove medication patches
Remove any opioid-containing medication patches (Figure 1).
Re-assessment
Make sure to re-assess the patient after any intervention.
Re-assessment and escalation
Re-assess the patient using the ABCDE approach to identify any changes in their clinical condition and assess the
e
Any clinical deterioration should be recognised quickly and acted upon immediately.
Seek senior help if the patient shows no signs of improvement or if you have any concerns.
Escalation
Patients unresponsive to naloxone will require senior medical input to consider a naloxone infusion. Haemodynamically
unstable patients will require urgent critical care input.
Use an eSBAR handover to communicate the key information to other medical sta
Next steps
Take a history
Revisit history taking to explore relevant medical history. If the patient is confused, you might be able to get a collateral history
from sta
See our history taking guides for more details.
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Review medical records
Review the patient’s notes, charts and recent investigation results.
Review the patient’s current medications and check any regular medications are prescribed appropriately.
Document
Clearly document your ABCDE assessment, including history, examination, observations, investigations, interventions, and the
patient’s response.
See our documentation guides for more details.
Discuss
Discuss the patient’s clinical condition with a senior clinician using an SBAR handover.
Questions which may need to be considered include\:
Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Does the patient need reviewing by a specialist?
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