Opioid ToxicityAPPROACH

TOXICOLOGY AND BEHAVIORAL · 19 SECTIONS

⚲

476 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Undifferentiated Overdose Opioid Toxicity Opioid Withdrawal Alcohol Intoxication Alcohol Withdrawal Stimulant Toxicity Pediatric Ingestion Carbon Monoxide Exposure Inhalational Or Chemical Exposure Suicidal Ideation And Self Harm Risk Assessment Acute Psychosis And Mania Symptoms Anxiety And Panic Symptoms Capacity Assessment And Safe Disposition Behavioral Escalation And Restraint Considerations

Pediatrics16▾

Environmental and Exposure4▾

01History/hx42

Exposure timeline

›Exposure and timeline

›Time last known well

›Time found unresponsive

›Time of naloxone given and response

›Duration of response after naloxone

Opioid and co ingestion details

›Substance details

›Suspected opioid

›Route

›Amount

›Formulation

›Immediate release

›Extended release

›Source

›Prescribed

›Illicit

›Unknown

›Co ingestions

›Alcohol

›Benzodiazepines

›Sedative hypnotics

›Clonidine

›Antipsychotics

›Gabapentinoids

›Stimulants

Symptom pattern and trajectory

›Course

›Progressive somnolence

›Episodic apnea

›Witnessed cyanosis

›Emesis

›Seizure like activity

Associated symptoms

›Associated symptoms

›Dyspnea

›Chest pain

›Cough

›Fever

›Headache

›Trauma history

Prior episodes and baseline

›Baseline and prior events

›Prior overdose episodes

›Prior naloxone response pattern

›Baseline respiratory disease

›Baseline mental status

02Alarm Features/alarm25

Immediate life threats

›Immediate escalation triggers

›Apnea

›Respiratory rate less than 8 per minute

›Oxygen saturation less than 90 percent despite oxygen

›Persistent hypoventilation with rising carbon dioxide

›GCS less than 13 with airway risk

›Recurrent sedation after naloxone

›Shock

›Refractory hypoglycemia

High risk contexts

›High risk contexts

›Long acting opioid exposure

›Body packing or stuffing concern

›Mixed sedative co ingestion

›Pregnancy

›Significant comorbidity

›COPD

›Obstructive sleep apnea

›Heart failure

›Pediatric exposure

High risk exam findings

›High risk exam findings

›Inability to protect airway

›Rales or frothy sputum

›Focal neurologic deficit

›Hyperthermia

›Hypothermia

03Medications/meds45

Home and recent medications

›Medication exposures

›Prescribed opioids

›Methadone

›Buprenorphine

›Benzodiazepines

›Z drugs

›Clonidine

›Gabapentin

›Pregabalin

›Antipsychotics

›Tricyclic antidepressants

›Beta blockers

Opioid reversal and sedation management

›Naloxone strategy

›IV naloxone initial dose

›0.04 mg

›Escalate every 2 to 3 minutes if inadequate ventilation

›0.1 mg

›0.2 mg

›0.4 mg

›2 mg

›Intranasal naloxone

›4 mg device

›Repeat every 2 to 3 minutes if inadequate ventilation

›IM naloxone

›0.4 mg

›Repeat every 2 to 3 minutes if inadequate ventilation

›Naloxone infusion

›Indication

›Recurrent respiratory depression after bolus

›Long acting opioid exposure

›Starting rate

›Two thirds of effective bolus dose per hour

›Titration

›Titrate every 5 to 15 minutes to ventilation target

›Wean after sustained clinical stability and falling opioid effect

›Naloxone adverse effects

›Acute withdrawal

›Agitation

›Vomiting

›Aspiration risk

›Pulmonary edema

Medication contraindications and traps

›Cautions

›Avoid flumazenil in mixed overdose with chronic benzodiazepine use

›Avoid excessive naloxone dosing in chronic opioid use when ventilation adequate

›Avoid sedatives for agitation until hypoxia and hypercapnia addressed

04Diet/diet10

Recent intake and exposures

›Intake context

›Fasting

›Poor oral intake

›Recent vomiting

›Dehydration risk

Alcohol and other exposures

›Co exposures

›Alcohol

›Energy drinks

›Cannabis edibles

›Inhalants

05Review of Systems/ros19

Respiratory and cardiovascular

›Cardiopulmonary symptoms

›Dyspnea

›Cough

›Chest pain

›Palpitations

›Orthopnea

›Hemoptysis

Neurologic and toxidrome

›Neuro symptoms

›Altered level of consciousness

›Syncope

›Seizure

›Headache

›Weakness

›Visual changes

Infectious and systemic

›Systemic symptoms

›Fever

›Chills

›Myalgias

›Rash

06Collateral History and Family History/chafh15

Collateral source

›Collateral

›Source

›EMS

›Family

›Friends

›Bystanders

›Reliability

›Witnessed ingestion

›Pill bottles present

›Prior similar events

Family history

›Family history

›Sudden cardiac death

›Seizure disorder (G40.909)

›Long QT syndrome

›Substance use disorder

07Risk Factors/rf17

Patient factors

›Patient risk factors

›Opioid use disorder (F11.20)

›Prior overdose

›Recent abstinence

›Post detox

›Post incarceration

›Sleep disordered breathing

›Chronic lung disease

Exposure factors

›Exposure risks

›Unknown potency supply

›Fentanyl analog exposure risk

›Methadone exposure risk

›Transdermal opioid exposure risk

Special populations

›Special populations

›Pregnancy

›Older adult

›Pediatric unintentional ingestion

08Differential Diagnosis/ddx41

Life threatening

›Life threatening

›Opioid toxicity (T40.2)

›Triad

›Central nervous system depression

›Respiratory depression

›Miosis

›Mixed sedative overdose

›Benzodiazepines (T42.4)

›Z drugs (T42.6)

›Alcohol (T51.0)

›Hypoglycemia (E16.2)

›Rapid point of care glucose differentiation

›Intracranial hemorrhage (I61.9)

›Trauma

›Focal deficits

›Acute airway obstruction

›Aspiration

›Foreign body

›Sepsis (A41.9)

›Fever

›Hypotension

Common

›Common

›Intoxication with other substances

›Cannabis

›Antihistamines

›Syncope with post event confusion

›Post ictal state

›Dehydration with altered mentation

Less common

›Less common

›Clonidine toxicity (T46.5)

›Miosis

›Bradycardia

›Carbon monoxide exposure (T58)

›Multiple affected

›Headache

›Myxedema coma (E03.5)

›Hypothermia

›Bradycardia

›Adrenal crisis (E27.2)

›Hypotension

›Hyponatremia

09Past Medical History/pmh17

Relevant conditions

›Relevant history

›Opioid use disorder (F11.20)

›Chronic pain

›COPD (J44.9)

›Obstructive sleep apnea (G47.33)

›Heart failure (I50.9)

›Chronic kidney disease (N18.9)

›Liver disease

Prior procedures and devices

›Procedures and devices

›Tracheostomy history

›Home oxygen

›CPAP use

›Implanted pumps

Baseline function

›Baseline

›Baseline mental status

›Baseline mobility

›Baseline oxygen requirement

10Physical Exam/exam38

General and airway

›Initial appearance

›Level of consciousness

›Work of breathing

›Cyanosis

›Vomitus in oropharynx

›Airway protective reflexes

Vitals interpretation

›Vitals patterns

›Bradypnea

›Hypoxia

›Hypothermia

›Hypotension

›Bradycardia

Pupils and neurologic

›Neuro exam

›Pupils

›Size

›Reactivity

›Focal deficits

›Seizure activity

›Signs of head trauma

Respiratory and pulmonary edema

›Chest exam

›Breath sounds

›Wheeze

›Crackles

›Signs of aspiration

›Frothy sputum

Cardiovascular

›Circulation

›Perfusion

›Heart rate and rhythm

›Jugular venous distension

Skin and tox clues

›Skin findings

›Track marks

›Diaphoresis

›Rash

›Pressure injury from down time

Trauma survey

›Trauma screen

›Scalp and face injury

›Cervical spine tenderness

›Long bone deformity

11Lab Studies/labs31

Point of care and core labs

›Initial labs

›Point of care glucose

›Venous blood gas

›pH

›Carbon dioxide mmHg

›Bicarbonate mmol/L

›Electrolytes

›Sodium mmol/L

›Potassium mmol/L

›Chloride mmol/L

›Bicarbonate mmol/L

›Creatinine and urea

›CBC

Targeted tox and complications

›Targeted studies

›Acetaminophen level

›Timing pitfall

›Early level may be misleading without known ingestion time

›Salicylate level

›Ethanol level

›Creatine kinase

›Rhabdomyolysis risk with prolonged down time

›Troponin if chest pain or hypoxia

›Lactate if shock or sepsis concern

Infectious and aspiration evaluation

›Infection and aspiration

›Blood cultures if febrile or shock

›Procalcitonin local protocol dependent

›Respiratory viral testing when clinically indicated

Toxicology testing limitations

›Toxicology screening limitations

›Urine immunoassay false negatives for synthetic opioids

›Urine immunoassay false positives with some medications

›Management should be clinical syndrome based

12Imaging/img43

Scoring Systems

›Decision tools

›Canadian CT Head Rule

›Use

›Minor head injury with GCS 13 to 15

›Concern for clinically important brain injury

›Not use

›Anticoagulated on warfarin or DOACs

›Age younger than 16

›NEXUS C spine

›Use

›Trauma with possible cervical spine injury

›Low risk criteria assessment

›Not use

›Unreliable exam from intoxication with inability to assess midline tenderness

›Focal neurologic deficit present

MRI

›MRI role

›Indications

›Suspected anoxic brain injury with persistent coma

›Suspected spinal cord injury with normal CT and persistent deficit

›Limitations

›Limited availability in unstable patients

›Motion artifact in agitated patients

›CT indications

›CT head

›Persistent altered mental status without clear toxidrome resolution

›Focal neurologic deficit

›Head trauma signs

›CT cervical spine

›Trauma with unreliable exam

›Midline tenderness

›CT chest angiography

›Only if alternate diagnosis suspected

›Pulmonary embolism features

Ultrasound

›POCUS applications

›Lung ultrasound

›B lines suggesting pulmonary edema

›Consolidation suggesting aspiration pneumonia

›Cardiac ultrasound

›Gross LV function

›Pericardial effusion

›IVC assessment

›Volume status adjunct

›Pitfalls in ventilated patients

13Special Tests/spec15

Bedside monitoring and diagnostics

›Bedside tests

›Continuous pulse oximetry

›Capnography

›Hypoventilation detection

›Response to naloxone monitoring

›Temperature

›Hypothermia detection

›Hyperthermia detection

Airway and aspiration evaluation

›Airway and aspiration

›Airway assessment criteria

›Gag and cough reflexes

›Ability to handle secretions

›Chest radiograph

›Aspiration pneumonitis patterns

›Noncardiogenic pulmonary edema patterns

14ECG/ecg13

Indications and high risk patterns

›ECG use

›Co ingestion concern for cardiotoxic agents

›Chest pain

›Syncope

›Dysrhythmia on monitor

›High risk findings

›QRS widening

›QTc prolongation

›Brugada pattern

›Ischemic changes

›Serial ECG

›Repeat if evolving symptoms

›Repeat if delayed absorption concern

15Assessment/ax17

Working diagnosis and severity

›Opioid toxicity (T40.2)

›Severity markers

›Degree of respiratory depression

›Need for repeated naloxone

›Need for naloxone infusion

›Pulmonary edema presence

›Complications to rule out

›Aspiration pneumonitis

›Noncardiogenic pulmonary edema

›Trauma from collapse

›Rhabdomyolysis

›Hypoxic brain injury

Diagnostic uncertainty

›Alternative diagnoses

›Persistent coma despite adequate ventilation and naloxone response absent

›Focal neurologic deficits

›Fever with meningismus

›Severe metabolic derangement on labs

16Plan/plan34

First 5 minutes

›Immediate stabilization

›Airway positioning

›Bag valve mask ventilation for apnea or hypoventilation

›Oxygen to target saturation 92 to 96 percent

›Cardiac monitor

›IV access

›Point of care glucose with immediate correction if low

Naloxone and ventilation targets

›Reversal strategy

›Naloxone titration target

›Adequate ventilation

›Airway protection

›Avoid full arousal if not needed for ventilation

›If recurrent respiratory depression after initial response

›Start naloxone infusion

›Continue close capnography monitoring

Supportive care and complications

›Supportive care

›Aspiration risk reduction

›Lateral positioning

›Suction readiness

›Fluids if hypotension after ventilation corrected

›Active warming if hypothermia

›Treat agitation from withdrawal

›Verbal de escalation

›Antiemetic for vomiting

›Avoid respiratory depressant sedatives when possible

Reassessment loop

›Reassessment

›Repeat mental status and ventilation checks every 5 to 15 minutes until stable

›Repeat vitals every 15 minutes until stable

›Repeat capnography trend after each naloxone dose change

›Escalate to airway intervention if persistent hypoventilation despite naloxone

Consultation

›Consultation plan

›Poison control or toxicology

›Critical care if infusion or airway support needed

›Addiction medicine or social work when clinically stable

17Disposition/dispo26

Level of care criteria

›ICU criteria

›Naloxone infusion requirement

›Need for invasive ventilation

›Persistent hypercapnia with acidemia

›Hemodynamic instability

›Pulmonary edema requiring high flow oxygen or positive pressure

›Inpatient admission criteria

›Recurrent respiratory depression during observation

›Aspiration pneumonia requiring antibiotics and oxygen

›Rhabdomyolysis with rising creatinine or high CK

›Significant comorbid respiratory disease with prolonged monitoring need

Observation pathway

›ED observation criteria

›Short acting opioid suspected with complete response to naloxone

›Stable vitals and ventilation after reversal

›Reliable monitoring available

Discharge criteria

›Discharge criteria

›Normal mentation

›Sustained adequate ventilation without naloxone re dosing

›Oxygen saturation stable on room air at baseline

›Ambulation at baseline

›No concerning trauma findings

›Safe supervision and follow up plan

Follow up timing

›Follow up

›Primary care within 1 to 7 days

›Addiction services within 24 to 72 hours when available

›Pharmacy or community naloxone program same day if possible

18Discharge Instructions/di18

Copy discharge instructions

›Discharge text

›Today you were treated for opioid poisoning that slowed your breathing

›Your breathing and alertness improved after naloxone and observation

›Do not use opioids or other sedatives for at least 24 hours

›Avoid alcohol and sleeping pills

›Do not drive or operate machinery for 24 hours

›Naloxone kit provided or prescription provided

›If you become very sleepy or your breathing slows again call emergency services immediately

›Return now for

›Trouble breathing

›Blue lips or face

›Fainting

›Chest pain

›Fever

›Vomiting with choking

›New weakness

›Severe headache

›Follow up with your doctor and addiction supports as arranged

19References/r10

Guidelines and key evidence

›Sources

›American Heart Association

›2020 Guidelines for CPR and ECC opioid associated emergency updates 2020

›World Health Organization

›Community management of opioid overdose guideline 2014

›Substance Abuse and Mental Health Services Administration

›Opioid overdose prevention toolkit updated edition local protocol dependent

›American College of Medical Toxicology and American Academy of Clinical Toxicology

›Position statements on naloxone use and opioid poisoning management year varies local protocol dependent

›Project instructions file

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Opioid ToxicityAPPROACH

TOXICOLOGY AND BEHAVIORAL · 19 SECTIONS

⚲

476 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx42

Exposure timeline

›Exposure and timeline

›Time last known well

›Time found unresponsive

›Time of naloxone given and response

›Duration of response after naloxone

Opioid and co ingestion details

›Substance details

›Suspected opioid

›Route

›Amount

›Formulation

›Immediate release

›Extended release

›Source

›Prescribed

›Illicit

›Unknown

›Co ingestions

›Alcohol

›Benzodiazepines

›Sedative hypnotics

›Clonidine

›Antipsychotics

›Gabapentinoids

›Stimulants

Symptom pattern and trajectory

›Course

›Progressive somnolence

›Episodic apnea

›Witnessed cyanosis

›Emesis

›Seizure like activity

Associated symptoms

›Associated symptoms

›Dyspnea

›Chest pain

›Cough

›Fever

›Headache

›Trauma history

Prior episodes and baseline

›Baseline and prior events

›Prior overdose episodes

›Prior naloxone response pattern

›Baseline respiratory disease

›Baseline mental status

02Alarm Features/alarm25

Immediate life threats

›Immediate escalation triggers

›Apnea

›Respiratory rate less than 8 per minute

›Oxygen saturation less than 90 percent despite oxygen

›Persistent hypoventilation with rising carbon dioxide

›GCS less than 13 with airway risk

›Recurrent sedation after naloxone

›Shock

›Refractory hypoglycemia

High risk contexts

›High risk contexts

›Long acting opioid exposure

›Body packing or stuffing concern

›Mixed sedative co ingestion

›Pregnancy

›Significant comorbidity

›COPD

›Obstructive sleep apnea

›Heart failure

›Pediatric exposure

High risk exam findings

›High risk exam findings

›Inability to protect airway

›Rales or frothy sputum

›Focal neurologic deficit

›Hyperthermia

›Hypothermia

03Medications/meds45

Home and recent medications

›Medication exposures

›Prescribed opioids

›Methadone

›Buprenorphine

›Benzodiazepines

›Z drugs

›Clonidine

›Gabapentin

›Pregabalin

›Antipsychotics

›Tricyclic antidepressants

›Beta blockers

Opioid reversal and sedation management

›Naloxone strategy

›IV naloxone initial dose

›0.04 mg

›Escalate every 2 to 3 minutes if inadequate ventilation

›0.1 mg

›0.2 mg

›0.4 mg

›2 mg

›Intranasal naloxone

›4 mg device

›Repeat every 2 to 3 minutes if inadequate ventilation

›IM naloxone

›0.4 mg

›Repeat every 2 to 3 minutes if inadequate ventilation

›Naloxone infusion

›Indication

›Recurrent respiratory depression after bolus

›Long acting opioid exposure

›Starting rate

›Two thirds of effective bolus dose per hour

›Titration

›Titrate every 5 to 15 minutes to ventilation target

›Wean after sustained clinical stability and falling opioid effect

›Naloxone adverse effects

›Acute withdrawal

›Agitation

›Vomiting

›Aspiration risk

›Pulmonary edema

Medication contraindications and traps

›Cautions

›Avoid flumazenil in mixed overdose with chronic benzodiazepine use

›Avoid excessive naloxone dosing in chronic opioid use when ventilation adequate

›Avoid sedatives for agitation until hypoxia and hypercapnia addressed

04Diet/diet10

Recent intake and exposures

›Intake context

›Fasting

›Poor oral intake

›Recent vomiting

›Dehydration risk

Alcohol and other exposures

›Co exposures

›Alcohol

›Energy drinks

›Cannabis edibles

›Inhalants

05Review of Systems/ros19

Respiratory and cardiovascular

›Cardiopulmonary symptoms

›Dyspnea

›Cough

›Chest pain

›Palpitations

›Orthopnea

›Hemoptysis

Neurologic and toxidrome

›Neuro symptoms

›Altered level of consciousness

›Syncope

›Seizure

›Headache

›Weakness

›Visual changes

Infectious and systemic

›Systemic symptoms

›Fever

›Chills

›Myalgias

›Rash

06Collateral History and Family History/chafh15

Collateral source

›Collateral

›Source

›EMS

›Family

›Friends

›Bystanders

›Reliability

›Witnessed ingestion

›Pill bottles present

›Prior similar events

Family history

›Family history

›Sudden cardiac death

›Seizure disorder (G40.909)

›Long QT syndrome

›Substance use disorder

07Risk Factors/rf17

Patient factors

›Patient risk factors

›Opioid use disorder (F11.20)

›Prior overdose

›Recent abstinence

›Post detox

›Post incarceration

›Sleep disordered breathing

›Chronic lung disease

Exposure factors

›Exposure risks

›Unknown potency supply

›Fentanyl analog exposure risk

›Methadone exposure risk

›Transdermal opioid exposure risk

Special populations

›Special populations

›Pregnancy

›Older adult

›Pediatric unintentional ingestion

08Differential Diagnosis/ddx41

Life threatening

›Life threatening

›Opioid toxicity (T40.2)

›Triad

›Central nervous system depression

›Respiratory depression

›Miosis

›Mixed sedative overdose

›Benzodiazepines (T42.4)

›Z drugs (T42.6)

›Alcohol (T51.0)

›Hypoglycemia (E16.2)

›Rapid point of care glucose differentiation

›Intracranial hemorrhage (I61.9)

›Trauma

›Focal deficits

›Acute airway obstruction

›Aspiration

›Foreign body

›Sepsis (A41.9)

›Fever

›Hypotension

Common

›Common

›Intoxication with other substances

›Cannabis

›Antihistamines

›Syncope with post event confusion

›Post ictal state

›Dehydration with altered mentation

Less common

›Less common

›Clonidine toxicity (T46.5)

›Miosis

›Bradycardia

›Carbon monoxide exposure (T58)

›Multiple affected

›Headache

›Myxedema coma (E03.5)

›Hypothermia

›Bradycardia

›Adrenal crisis (E27.2)

›Hypotension

›Hyponatremia

09Past Medical History/pmh17

Relevant conditions

›Relevant history

›Opioid use disorder (F11.20)

›Chronic pain

›COPD (J44.9)

›Obstructive sleep apnea (G47.33)

›Heart failure (I50.9)

›Chronic kidney disease (N18.9)

›Liver disease

Prior procedures and devices

›Procedures and devices

›Tracheostomy history

›Home oxygen

›CPAP use

›Implanted pumps

Baseline function

›Baseline

›Baseline mental status

›Baseline mobility

›Baseline oxygen requirement

10Physical Exam/exam38

General and airway

›Initial appearance

›Level of consciousness

›Work of breathing

›Cyanosis

›Vomitus in oropharynx

›Airway protective reflexes

Vitals interpretation

›Vitals patterns

›Bradypnea

›Hypoxia

›Hypothermia

›Hypotension

›Bradycardia

Pupils and neurologic

›Neuro exam

›Pupils

›Size

›Reactivity

›Focal deficits

›Seizure activity

›Signs of head trauma

Respiratory and pulmonary edema

›Chest exam

›Breath sounds

›Wheeze

›Crackles

›Signs of aspiration

›Frothy sputum

Cardiovascular

›Circulation

›Perfusion

›Heart rate and rhythm

›Jugular venous distension

Skin and tox clues

›Skin findings

›Track marks

›Diaphoresis

›Rash

›Pressure injury from down time

Trauma survey

›Trauma screen

›Scalp and face injury

›Cervical spine tenderness

›Long bone deformity

11Lab Studies/labs31

Point of care and core labs

›Initial labs

›Point of care glucose

›Venous blood gas

›pH

›Carbon dioxide mmHg

›Bicarbonate mmol/L

›Electrolytes

›Sodium mmol/L

›Potassium mmol/L

›Chloride mmol/L

›Bicarbonate mmol/L

›Creatinine and urea

›CBC

Targeted tox and complications

›Targeted studies

›Acetaminophen level

›Timing pitfall

›Early level may be misleading without known ingestion time

›Salicylate level

›Ethanol level

›Creatine kinase

›Rhabdomyolysis risk with prolonged down time

›Troponin if chest pain or hypoxia

›Lactate if shock or sepsis concern

Infectious and aspiration evaluation

›Infection and aspiration

›Blood cultures if febrile or shock

›Procalcitonin local protocol dependent

›Respiratory viral testing when clinically indicated

Toxicology testing limitations

›Toxicology screening limitations

›Urine immunoassay false negatives for synthetic opioids

›Urine immunoassay false positives with some medications

›Management should be clinical syndrome based

12Imaging/img43

Scoring Systems

›Decision tools

›Canadian CT Head Rule

›Use

›Minor head injury with GCS 13 to 15

›Concern for clinically important brain injury

›Not use

›Anticoagulated on warfarin or DOACs

›Age younger than 16

›NEXUS C spine

›Use

›Trauma with possible cervical spine injury

›Low risk criteria assessment

›Not use

›Unreliable exam from intoxication with inability to assess midline tenderness

›Focal neurologic deficit present

MRI

›MRI role

›Indications

›Suspected anoxic brain injury with persistent coma

›Suspected spinal cord injury with normal CT and persistent deficit

›Limitations

›Limited availability in unstable patients

›Motion artifact in agitated patients

›CT indications

›CT head

›Persistent altered mental status without clear toxidrome resolution

›Focal neurologic deficit

›Head trauma signs

›CT cervical spine

›Trauma with unreliable exam

›Midline tenderness

›CT chest angiography

›Only if alternate diagnosis suspected

›Pulmonary embolism features

Ultrasound

›POCUS applications

›Lung ultrasound

›B lines suggesting pulmonary edema

›Consolidation suggesting aspiration pneumonia

›Cardiac ultrasound

›Gross LV function

›Pericardial effusion

›IVC assessment

›Volume status adjunct

›Pitfalls in ventilated patients

13Special Tests/spec15

Bedside monitoring and diagnostics

›Bedside tests

›Continuous pulse oximetry

›Capnography

›Hypoventilation detection

›Response to naloxone monitoring

›Temperature

›Hypothermia detection

›Hyperthermia detection

Airway and aspiration evaluation

›Airway and aspiration

›Airway assessment criteria

›Gag and cough reflexes

›Ability to handle secretions

›Chest radiograph

›Aspiration pneumonitis patterns

›Noncardiogenic pulmonary edema patterns

14ECG/ecg13

Indications and high risk patterns

›ECG use

›Co ingestion concern for cardiotoxic agents

›Chest pain

›Syncope

›Dysrhythmia on monitor

›High risk findings

›QRS widening

›QTc prolongation

›Brugada pattern

›Ischemic changes

›Serial ECG

›Repeat if evolving symptoms

›Repeat if delayed absorption concern

15Assessment/ax17

Working diagnosis and severity

›Opioid toxicity (T40.2)

›Severity markers

›Degree of respiratory depression

›Need for repeated naloxone

›Need for naloxone infusion

›Pulmonary edema presence

›Complications to rule out

›Aspiration pneumonitis

›Noncardiogenic pulmonary edema

›Trauma from collapse

›Rhabdomyolysis

›Hypoxic brain injury

Diagnostic uncertainty

›Alternative diagnoses

›Persistent coma despite adequate ventilation and naloxone response absent

›Focal neurologic deficits

›Fever with meningismus

›Severe metabolic derangement on labs

16Plan/plan34

First 5 minutes

›Immediate stabilization

›Airway positioning

›Bag valve mask ventilation for apnea or hypoventilation

›Oxygen to target saturation 92 to 96 percent

›Cardiac monitor

›IV access

›Point of care glucose with immediate correction if low

Naloxone and ventilation targets

›Reversal strategy

›Naloxone titration target

›Adequate ventilation

›Airway protection

›Avoid full arousal if not needed for ventilation

›If recurrent respiratory depression after initial response

›Start naloxone infusion

›Continue close capnography monitoring

Supportive care and complications

›Supportive care

›Aspiration risk reduction

›Lateral positioning

›Suction readiness

›Fluids if hypotension after ventilation corrected

›Active warming if hypothermia

›Treat agitation from withdrawal

›Verbal de escalation

›Antiemetic for vomiting

›Avoid respiratory depressant sedatives when possible

Reassessment loop

›Reassessment

›Repeat mental status and ventilation checks every 5 to 15 minutes until stable

›Repeat vitals every 15 minutes until stable

›Repeat capnography trend after each naloxone dose change

›Escalate to airway intervention if persistent hypoventilation despite naloxone

Consultation

›Consultation plan

›Poison control or toxicology

›Critical care if infusion or airway support needed

›Addiction medicine or social work when clinically stable

17Disposition/dispo26

Level of care criteria

›ICU criteria

›Naloxone infusion requirement

›Need for invasive ventilation

›Persistent hypercapnia with acidemia

›Hemodynamic instability

›Pulmonary edema requiring high flow oxygen or positive pressure

›Inpatient admission criteria

›Recurrent respiratory depression during observation

›Aspiration pneumonia requiring antibiotics and oxygen

›Rhabdomyolysis with rising creatinine or high CK

›Significant comorbid respiratory disease with prolonged monitoring need

Observation pathway

›ED observation criteria

›Short acting opioid suspected with complete response to naloxone

›Stable vitals and ventilation after reversal

›Reliable monitoring available

Discharge criteria

›Discharge criteria

›Normal mentation

›Sustained adequate ventilation without naloxone re dosing

›Oxygen saturation stable on room air at baseline

›Ambulation at baseline

›No concerning trauma findings

›Safe supervision and follow up plan

Follow up timing

›Follow up

›Primary care within 1 to 7 days

›Addiction services within 24 to 72 hours when available

›Pharmacy or community naloxone program same day if possible

18Discharge Instructions/di18

Copy discharge instructions

›Discharge text

›Today you were treated for opioid poisoning that slowed your breathing

›Your breathing and alertness improved after naloxone and observation

›Do not use opioids or other sedatives for at least 24 hours

›Avoid alcohol and sleeping pills

›Do not drive or operate machinery for 24 hours

›Naloxone kit provided or prescription provided

›If you become very sleepy or your breathing slows again call emergency services immediately

›Return now for

›Trouble breathing

›Blue lips or face

›Fainting

›Chest pain

›Fever

›Vomiting with choking

›New weakness

›Severe headache

›Follow up with your doctor and addiction supports as arranged

19References/r10

Guidelines and key evidence

›Sources

›American Heart Association

›2020 Guidelines for CPR and ECC opioid associated emergency updates 2020

›World Health Organization

›Community management of opioid overdose guideline 2014

›Substance Abuse and Mental Health Services Administration

›Opioid overdose prevention toolkit updated edition local protocol dependent

›American College of Medical Toxicology and American Academy of Clinical Toxicology

›Position statements on naloxone use and opioid poisoning management year varies local protocol dependent

›Project instructions file

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.