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